[Federal Register Volume 71, Number 226 (Friday, November 24, 2006)]
[Rules and Regulations]
[Pages 67960-68401]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 06-9079]



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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, 416 et al.



Medicare Program--Revisions to Hospital Outpatient Prospective Payment 
System and Calendar Year 2007 Payment Rates; Final Rule

  Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / 
Rules and Regulations  

[[Page 67960]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 410, 416, 419, 421, 485, and 488

[CMS-1506-FC; CMS-4125-F]
RIN 0938-AO15


Medicare Program; Hospital Outpatient Prospective Payment System 
and CY 2007 Payment Rates; CY 2007 Update to the Ambulatory Surgical 
Center Covered Procedures List; Medicare Administrative Contractors; 
and Reporting Hospital Quality Data for FY 2008 Inpatient Prospective 
Payment System Annual Payment Update Program--HCAHPS Survey, SCIP, and 
Mortality

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

ACTION: Final rule with comment period and final rule.

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SUMMARY: This final rule with comment period revises the Medicare 
hospital outpatient prospective payment system to implement applicable 
statutory requirements and changes arising from our continuing 
experience with this system, and to implement certain related 
provisions of the Medicare Prescription Drug, Improvement, and 
Modernization Act (MMA) of 2003 and the Deficit Reduction Act (DRA) of 
2005. In this final rule with comment period, we describe changes to 
the amounts and factors used to determine the payment rates for 
Medicare hospital outpatient services paid under the prospective 
payment system. These changes are applicable to services furnished on 
or after January 1, 2007. In addition, this final rule with comment 
period implements future CY 2009 required reporting on quality measures 
for hospital outpatient services paid under the prospective payment 
system.
    This final rule with comment period revises the current list of 
procedures that are covered when furnished in a Medicare-approved 
ambulatory surgical center (ASC), which are applicable to services 
furnished on or after January 1, 2007.
    This final rule with comment period revises the emergency medical 
screening requirements for critical access hospitals (CAHs).
    This final rule with comment period supports implementation of a 
restructuring of the contracting entities responsibilities and 
functions that support the adjudication of Medicare fee-for-service 
(FFS) claims. This restructuring is directed by section 1874A of the 
Act, as added by section 911 of the MMA. The prior separate Medicare 
intermediary and Medicare carrier contracting authorities under Title 
XVIII of the Act have been replaced with the Medicare Administrative 
Contractor (MAC) authority.
    This final rule continues to implement the requirements of the DRA 
that require that we expand the ``starter set'' of 10 quality measures 
that we used in FY 2005 and FY 2006 for the hospital inpatient 
prospective payment system (IPPS) Reporting Hospital Quality Data for 
the Annual Payment Update (RHQDAPU) program. We began to adopt expanded 
measures effective for payments beginning in FY 2007. In this rule, we 
are finalizing additional quality measures for the expanded set of 
measures for FY 2008 payment purposes. These measures include the 
HCAHPS survey, as well as Surgical Care Improvement Project (SCIP, 
formerly Surgical Infection Prevention (SIP)), and Mortality quality 
measures.

DATES: Effective Date: The provisions of these final rules are 
effective on January 1, 2007.
    Comment Period: We will consider comments on the payment 
classification assigned to HCPCS codes identified in Addendum B with 
the NI comment code, and other areas specified throughout the preamble, 
at the appropriate address, as provided below, no later than 5 p.m. 
January 23, 2007.
    Application Deadline--New Class of New Technology Intraocular Lens: 
Requests for review of applications for a new class of new technology 
intraocular lenses must be received by close of business April 1, 2007.

ADDRESSES: In commenting, please refer to file code CMS-1506-FC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click 
on the link ``Submit electronic comments on CMS regulations with an 
open comment period.'' (Attachments should be in Microsoft Word, 
WordPerfect, or Excel; however, we prefer Microsoft Word.)
    2. By regular mail. You may 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-1506-FC, P.O. Box 8011, Baltimore, MD 
21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send 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-1506-FC, Mail Stop C4-26-05, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses: Room 
445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-
1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal Government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing 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 received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.
    Applications for a new class of new technology intraocular lenses: 
Requests for review of applications for a new class of new technology 
intraocular lenses must be sent by regular mail to: ASC/NTIOL, Division 
of Outpatient Care, Mailstop C4-05-17, Centers for Medicare and 
Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

FOR FURTHER INFORMATION CONTACT:
Alberta Dwivedi, (410) 786-0378, Hospital outpatient prospective 
payment issues.
Dana Burley, (410) 786-0378, Ambulatory surgery center issues.
Suzanne Asplen, (410) 786-4558, Partial hospitalization and community 
mental health centers issues.

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Mary Collins, (410) 786-3189, Critical access hospital emergency 
medical planning issues.
Sandra M. Clarke, (410) 786-6975, Medicare Administrative Contractors 
issues.
Mark Zobel, (410) 786-6905, Medicare Administrative Contractors issues.
Liz Goldstein, (410) 786-6665, FY 2008 IPPS RHQDAPU HCAHPS issues.
Bill Lehrman, (410) 786-1037, FY 2008 IPPS RHQDAPU HCAHPS issues.
Sheila Blackstock, (410) 786-3506, FY 2008 IPPS RHQDAPU SCIP and 
mortality issues.

SUPPLEMENTARY INFORMATION: Submitting Comments: We welcome comments 
from the public on the payment classification and status indicator 
assigned to HCPCS codes identified in Addendum B of this final rule 
with comment period with comment indicator NI and on the ambulatory 
surgical center procedures that were not proposed for addition to the 
ambulatory surgical center list in the CY 2007 OPPS proposed rule to 
assist us in fully considering issues and developing policies. You can 
assist us by referencing filed code CMS-1506-FC.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on 
CMS Regulations'' on that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, MD 21244, on Monday through Friday of each week from 8:30 
a.m. to 4:00 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

Electronic Access

    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. Free public access is available on a Wide 
Area Information Server (WAIS) through the Internet and via 
asynchronous dial-in. Internet users can access the database by using 
the World Wide Web; the Superintendent of Documents' home page address 
is http://www.gpoaccess.gov/index.html, by using local WAIS client 
software, or by telnet to swais.access.gpo.gov, then log in as guest 
(no password required). Dial-in users should use communications 
software and modem to call (202) 512-1661; type swais, then log in as 
guest (no password required).

Alphabetical List of Acronyms Appearing in the Final Rule

ACEP American College of Emergency Physicians
AHA American Hospital Association
AHIMA American Health Information Management Association
AMA American Medical Association
APC Ambulatory payment classification
AMP Average manufacturer price
ASC Ambulatory Surgical Center
ASP Average sales price
AWP Average wholesale price
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance 
Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113
BCA Blue Cross Association
BCBSA Blue Cross and Blue Shield Association
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000, Pub. L. 106-554
CAH Critical access hospital
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CMHC Community mental health center
CMS Centers for Medicare & Medicaid Services
CNS Clinical nurse specialist
CORF Comprehensive outpatient rehabilitation facility
CPT [Physicians'] Current Procedural Terminology, Fourth Edition, 2006, 
copyrighted by the American Medical Association
CRNA Certified registered nurse anesthetist
CY Calendar year
DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies
DMERC Durable medical equipment regional carrier
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DSH Disproportionate share hospital
EACH Essential Access Community Hospital
E/M Evaluation and management
EPO Erythropoietin
ESRD End-stage renal disease
FACA Federal Advisory Committee Act, Pub. L. 92-463
FAR Federal Acquisition Regulations
FDA Food and Drug Administration
FFS Fee-for-service
FSS Federal Supply Schedule
FY Federal fiscal year
GAO Government Accountability Office
HCPCS Healthcare Common Procedure Coding System
HCRIS Hospital Cost Report Information System
HHA Home health agency
HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. 
L. 104-191
ICD-9-CM International Classification of Diseases, Ninth Edition, 
Clinical Modification
IDE Investigational device exemption
IOL Intraocular lens
IPPS [Hospital] Inpatient prospective payment system
IVIG Intravenous immune globulin
MAC Medicare Administrative Contractors
MedPAC Medicare Payment Advisory Commission
MDH Medicare-dependent, small rural hospital
MMA Medicare Prescription Drug, Improvement, and Modernization Act of 
2003, Pub. L. 108-173
MPFS Medicare Physician Fee Schedule
MSA Metropolitan Statistical Area
NCCI National Correct Coding Initiative
NCD National Coverage Determination
NTIOL New technology intraocular lens
OCE Outpatient Code Editor
OMB Office of Management and Budget
OPD [Hospital] Outpatient department
OPPS [Hospital] Outpatient prospective payment system
PHP Partial hospitalization program
PM Program memorandum
PPI Producer Price Index
PPS Prospective payment system
PPV Pneumococcal pneumonia (virus)
PRA Paperwork Reduction Act
QIO Quality Improvement Organization
RFA Regulatory Flexibility Act
RHQDAPU Reporting hospital quality data for annual payment update
RHHI Regional home health intermediary
SBA Small Business Administration
SCH Sole community hospital
SDP Single Drug Pricer
SI Status indicator
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248
TOPS Transitional outpatient payments
USPDI United States Pharmacopoeia Drug Information


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    In this document, we address three payment systems under the 
Medicare program: the hospital outpatient prospective payment system 
(OPPS), the hospital inpatient prospective payment system (IPPS), and 
the ambulatory surgical center (ASC) payment system. The provisions 
relating to the OPPS are included in sections I. through XIII., XV., 
XVI., XIX., XXIII., XXIV., XXV., and XXVI. of the preamble and in 
Addenda A, B, C (Addendum C is available on the Internet only; see 
section XXIII. of the preamble of this final rule with comment period), 
D1, D2, and E of this final rule with comment period. The provisions 
related to the IPPS are included in sections XXII. and XXVI.E. of the 
preamble. The provisions related to ASCs are included in sections XVII. 
and XXV., and XXVI.C. of the preamble and in Addenda AA of this final 
rule with comment period.
    In addition, in this document, we address our implementation of the 
Medicare contracting reform provisions of the MMA that replace the 
prior Medicare intermediary and carrier authorities formerly found in 
sections 1816 and 1842 of the Act with Medicare administrative 
contractor (MAC) authority under a new section 1874A of the Act. The 
provisions relating to MACs are included in sections XVIII. and XXV.D. 
of this preamble. To assist readers in referencing sections contained 
in this document, we are providing the following table of contents:

Table of Contents

I. Background for the OPPS
    A. Legislative and Regulatory Authority for the Hospital 
Outpatient Prospective Payment System
    B. Excluded OPPS Services and Hospitals
    C. Prior Rulemaking
    D. APC Advisory Panel
    1. Authority of the APC Panel
    2. Establishment of the APC Panel
    3. APC Panel Meetings and Organizational Structure
    E. Provisions of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003
    1. Reduction in Threshold for Separate APCs for Drugs
    2. Special Payment for Brachytherapy
    F. Provisions of the Deficit Reduction Act (DRA) of 2005
    1. 3-Year Transition of Hold Harmless Payments
    2. Medicare Coverage of Ultrasound Screening for Abdominal 
Aortic Aneurysms
    3. Colorectal Cancer Screening
    G. Summary of the Provisions of the CY 2007 OPPS Proposed Rule
    1. Updates to the OPPS Payments for CY 2007
    2. Ambulatory Payment Classification (APC) Group Policies
    3. Payment Changes for Devices
    4. Payment Changes for Drugs, Biologicals, and 
Radiopharmaceuticals
    5. Estimate of Transitional Pass-Through Spending in CY 2007 for 
Drugs, Biologicals, and Devices
    6. Brachytherapy Payment Changes
    7. Coding and Payment for Drugs Administration
    8. Hospital Coding and Payments for Visits
    9. Payment for Blood and Blood Products
    10. Payment for Observation Services
    11. Procedures That Will Be Paid Only as Inpatient Services
    12. Nonrecurring Policy Changes
    13. Emergency Medical Screening in Critical Access Hospitals 
(CAHs)
    14. Payment Status and Comment Indicator Assignments
    15. OPPS Policy and Payment Recommendations
    16. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 
2007
    17. Revised ASC Payment System for Implementation January 1, 
2008
    18. Medicare Contracting Reform Mandate
    19. Reporting Quality Data for Improved Quality and Costs Under 
the OPPS
    20. Promoting Effective Use of Health Information Technology
    21. Health Care Information Transparency Initiative
    22. Additional Quality Measures and Procedures for Hospital 
Reporting of Quality Data for FY 2008 IPPS Annual Payment Update
    23. Impact Analysis
    H. Public Comments Received in Response to the CY 2007 OPPS and 
Reporting Hospital Quality Data for FY 2008 IPPS Annual Payment 
Update Program--HCAHPS Survey, SCIP, and Mortality Proposed Rules
    I. Public Comments Received on the November 10, 2005 OPPS Final 
Rule with Comment Period
II. Updates Affecting OPPS Payments for CY 2007
    A. Recalibration of APC Relative Weights for CY 2007
    1. Database Construction
    a. Database Source and Methodology
    b. Use of Single and Multiple Procedure Claims
    c. Revised Overall Cost-to-Charge Ratio (CCR) Calculation
    2. Calculation of Median Costs for CY 2007
    3. Calculation of Scaled OPPS Payment Weights
    4. Changes to Packaged Services
    B. Payment for Partial Hospitalization
    1. Background
    2. PHP APC Update for CY 2007
    3. Separate Threshold for Outlier Payments to CMHCs
    C. Conversion Factor Update for CY 2007
    D. Wage Index Changes for CY 2007
    E. Statewide Average Default CCRs
    F. OPPS Payments to Certain Rural Hospitals
    1. Hold Harmless Transitional Payment Changes Made by Pub. L. 
109-171 (DRA)
    2. Adjustment for Rural SCHs Implemented in CY 2006 Related to 
Pub. L. 108-173 (MMA)
    G. CY 2007 Hospital Outpatient Outlier Payments
    1. CY 2007 Proposal
    2. CY 2007 Final Rule Outlier Calculation
    H. Calculation of the OPPS National Unadjusted Medicare Payment
    I. Beneficiary Copayments for CY 2007
    1. Background
    2. Copayment for CY 2007
    3. Calculation of an Adjusted Copayment Amount for an APC Group 
for CY 2007
III. OPPS Ambulatory Payment Classification (APC) Group Policies
    A. Treatment of New HCPCS and CPT Codes
    1. Treatment of New HCPCS Codes Included in the Second and Third 
Quarterly OPPS Updates for CY 2006
    2. Treatment of New CY 2007 Category I and III CPT Codes and 
Level II HCPCS Codes
    3. Treatment of New Mid-Year CPT Codes
    B. Variations Within APCs
    1. Background
    2. Application of the 2 Times Rule
    3. Exceptions to the 2 Times Rule
    C. New Technology APCs
    1. Introduction
    2. Movement of Procedures from New Technology APCs to Clinical 
APCs
    a. Nonmyocardial Positron Emission Tomography (PET) Scans (APC 
0308)
    b. PET/Computed Tomography (CT) Scans (APC 0308)
    c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services 
(APCs 0065, 0066, and 0067)
    d. Magnetoencephalography (MEG) Services (APCs 0038 and 0209)
    e. Other Services in New Technology APCs
    (1) Breast Brachytherapy (APCs 0029 and 0030)
    (2) Radiofrequency Ablation (APCs 0050 and 0423)
    (3) Extracorporeal Shock Wave Treatment (APC 0050)
    (4) Insertion of Venuous Access Device with Two Ports (APC 0623)
    (5) Stereoscopic X-Ray Guidance (APC 0257)
    (6) Whole Body Tumor Imaging (APC 0408)
    (7) Gastroesophageal Reflux Test With pH Electrode (APC 0361)
    (8) Home International Normalized Ratio (INR) Monitoring (APC 
0604)
    (9) Tositumomab Administration and Supply (APC 0442)
    (10) Summary of Other New Technology Procedures Assigned to 
Clinical APCs for CY 2007
    D. APC-Specific Policies
    1. Radiology Procedures
    a. Radiology Procedures (APCs 0333, 0662, and Other Imaging 
APCs)
    b. Computerized Reconstruction (APC 0417)
    c. Cardiac Computed Tomography and Computed Tomographic 
Angiography (APCs 0282, 0376, 0377, and 0398)
    d. Radiologic Evaluation of Central Venous Access Device (APC 
0340)
    2. Nuclear Medicine and Radiation Oncology Procedures
    a. Myocardial Positron Emission Tomography (PET) Scans (APC 
0307)
    b. Complex Interstitial Radiation Source Application (APC 0651)
    c. Proton Beam Therapy (APCs 0664 and 0667)

[[Page 67963]]

    d. Urinary Bladder Residual Study (APC 0340)
    e. Hyperthermia Treatment (APC 0314)
    f. Unlisted Procedure for Clinical Brachytherpy (APC 0312)
    3. Cardiac and Vascular Procedures
    a. Electrophysiologic Recording/Mapping (APC 0087)
    b. Endovenous Laser Ablation Procedures (APC 0092)
    c. Repair/Repositioning of Defibrillator Leads (APC 0106)
    d. Thrombectomy Procedures (APCs 0103 and 0653)
    4. Gastrointestinal and Genitourinary Procedures
    a. Insertion of Mesh or Other Prosthesis (APC 0195)
    b. Percutaneous Renal Cryoablation (APC 0423)
    c. Ultrasound Ablation of Uterine Fibroids with Magnetic 
Resonance Guidance (MRgFUS) (APCs 0195 and 0202)
    d. Laser Vaporization of Prostate (APC 0429)
    e. Gastrointestinal Procedures with Stents (APC 0384)
    f. Endoscopy with Thermal Energy to Sphincter (APC 0422)
    5. Ocular Procedures
    a. Keratoprosthesis (APC 0293)
    b. Eye Procedures (APCs 0232, 0235, and 0241)
    c. Amniotic Membrane for Ocular Surface Reconstruction
    6. Other Procedures
    a. Skin Replacement Surgery and Skin Substitutes (APC 0025)
    b. Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064)
    c. Complex Skin Repair (APC 0024)
    d. Insertion of Posterior Spinous Process Distraction Device
    7. Medical Services
    a. Medication Therapy Management Services
    b. Single Allergy Tests (APC 0381)
    c. Hyperbaric Oxygen Therapy (APC 0659)
    d. Guidance for Chemodenervation (APC 0215)
    e. Pathology Services (APC 0344)
IV. OPPS Payment Changes for Devices
    A. Treatment of Device-Dependent APCs
    1. Background
    2. CY 2007 Payment Policy
    3. Devices Billed in the Absence of an Appropriate Procedure 
Code
    4. Payment Policy When Devices are Replaced Without Cost or 
Where Credit for a Replaced Device is Furnished to the Hospital
    B. Pass-Through Payments for Devices
    1. Expiration of Transitional Pass-Through Payments for Certain 
Devices
    a. Background
    b. Policy for CY 2007
    2. Provisions for Reducing Transitional Pass-Through Payments to 
Offset Costs Packaged into APC Groups
    a. Background
    b. Policies for CY 2007
V. OPPS Payment Changes for Drugs, Biologicals, and 
Radiopharmaceuticals
    A. Transitional Pass-Through Payment for Additional Costs of 
Drugs and Biologicals
    1. Background
    2. Drugs and Biologicals With Expiring Pass-Through Status in CY 
2006
    3. Drugs and Biologicals With Pass-Through Status in CY 2007
    B. Payment for Drugs, Biologicals, and Radiopharmaceuticals 
Without Pass-Through Status
    1. Background
    2. Criteria for Packaging Payment for Drugs, Biologicals, and 
Radiopharmaceuticals
    3. Payment for Drugs, Biologicals, and Radiopharmaceuticals 
Without Pass-Through Status That Are Not Packaged
    a. Payment for Specified Covered Outpatient Drugs
    (1) Background
    (2) Payment Policy for CY 2007
    (3) CY 2007 Payment Policy for Radiopharmaceuticals
    (a) Background and Proposed CY 2007 Radiopharmaceutical Payment 
Policy
    (b) CY 2007 Final Radiopharmaceutical Payment Policy
    b. CY 2007 Payment for Nonpass-Through Drugs, Biologicals, 
Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital 
Claims Data
    (1) Background
    (2) CY 2007 Proposed and Final Payment Policy for 
Radiopharmaceuticals With HCPCS Codes, But Without Hospital Claims 
Data
    (3) CY 2007 Proposed and Final Payment Policy for Drugs and 
Biologicals With HCPCS Codes, But Without OPPS Hospital Claims Data
    (4) CY 2007 Proposed and Final Payment Policy for Drugs, 
Biologicals, and Radiopharmaceuticals With HCPCS Codes, But Without 
OPPS Hospital Claims Data and Without ASP-Related Data
VI. Estimate of OPPS Transitional Pass-Through Spending in CY 2007 
for Drugs, Biologicals, Radiopharmaceuticals, and Devices
    A. Total Allowed Pass-Through Spending
    B. Estimate of Pass-Through Spending for CY 2007
VII. Brachytherapy Source Payment Changes
    A. Background
    B. Government Accountability Office's Final Report on Devices of 
Brachytherapy
    C. Payments for Brachytherapy Sources in CY 2007
VIII. Changes to OPPS Drug Administration Coding and Payment for CY 
2007
    A. Background
    B. CY 2007 Drug Administration Coding Changes
    C. CY 2007 Drug Administration Payment Changes
IX. Hospital Coding and Payment for Visits
    A. Background
    1. Guidelines Based on the Number or Type of Staff Interventions
    2. Guidelines Based on the Time Staff Spent with the Patient
    3. Guidelines Based on a Point System Where a Certain Number of 
Points Are Assigned to Each Staff Intervention Based on the Time, 
Intensity, and Staff Type Required for the Intervention
    4. Guidelines Based on Patient Complexity
    B. CY 2007 Proposed and Final Coding Policies
    1. Clinic Visits
    2. Emergency Department Visits
    3. Critical Care Services
    C. CY 2007 Payment Policy
    D. CY 2007 Treatment of Guidelines
    1. Background
    2. Outstanding Concerns with the AHA/AHIMA Guidelines
    a. Three Versus Five Levels of Codes
    b. Lack of Clarity for Some Interventions
    c. Treatment of Separately Payable Services
    d. Some Interventions Appear Overvalued
    e. Concerns of Specialty Clinics
    f. American with Disabilities Act
    g. Differentiation Between New and Established Patients and 
Between Standard Visits and Consultations
    h. Distinction Between Type A and Type B Emergency Departments
X. Payment for Blood and Blood Products
    A. Background
    B. Policy Changes for CY 2007
XI. OPPS Payment for Observation Services
XII. Procedures That Will be Paid Only as Inpatient Procedures
    A. Background
    B. Changes to the Inpatient List
    C. CY 2007 Payment for Ancillary Outpatient Services When 
Patient Expires (-CA Modifier)
    1. Background
    2. Policy for CY 2007
XIII. Nonrecurring Policy Changes
    A. Removal of Comprehensive Outpatient Rehabilitation Facility 
(CORF) Services from the List of Services Paid under the OPPS
    B. Addition of Ultrasound Screening for Abdominal Aortic 
Aneurysms (AAAs) (Section 5112 of Pub. L. 109-171 (DRA))
    1. Background
    2. Assignment of New HCPCS Code and Payment for Ultrasound 
Screening for Abdominal Aortic Aneurysm (AAA)
XIV. Emergency Medical Screening in Critical Access Hospitals (CAHs)
    A. Background
    B. Proposed Policy Change
    C. Public Comments Received on the Proposal
    D. Final Policy
XV. OPPS Payment Status and Comment Indicators
    A. CY 2007 Status Indicator Definitions
    1. Payment Status Indicators to Designate Services That Are Paid 
under the OPPS
    2. Payment Status Indicators to Designate Services That Are Paid 
under a Payment System Other Than the OPPS
    3. Payment Status Indicators to Designate Services That Are Not 
Recognized under the OPPS But That May Be Recognized by Other 
Institutional Providers
    4. Payment Status Indicators to Designate Services That Are Not 
Payable by Medicare
    B. CY 2007 Comment Indicator Definitions
XVI. OPPS Policy and Payment Recommendations
    A. MedPAC Recommendations
    B. APC Panel Recommendations
    C. GAO Recommendations
XVII. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 
2007

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    A. ASC Background
    1. Legislative History
    2. Current Payment Method
    3. Published Changes to the ASC List
    B. ASC List Update Effective for Services Furnished On or After 
January 1, 2007
    1. Criteria for Additions To or Deletions From the ASC List
    2. Rationale for Payment Assignment
    3. Response to Comments to the May 4, 2005 Interim Final Rule 
for the ASC Update
    4. Procedures Proposed for Additions to the ASC List
    5. Specific Requests for Payment Group Changes
    6. Requests for Additions to the ASC List from Comments to the 
August 23, 2006 Proposed Rule
    a. Requests Accepted for Additions to the ASC List for CY 2007
    b. Requests Not Accepted for Additions to the ASC List for CY 
2007
    7. Requests for Payment Increases for Procedures on the Current 
ASC List
    8. Other Comments on the May 4, 2005 Interim Final Rule
    C. Regulatory Changes for CY 2007
    D. Implementation of Section 1834(d) of the Act
    E. Implementation of Section 5103 of Pub. L. 109-171 (DRA)
    F. Modification of the Current ASC Process for Adjusting Payment 
for New Technology Intraocular Lenses (NTIOLs)
    1. Background
    a. Current ASC Payment for Insertion of IOLs
    b. Classes of NTIOLs Approved for Payment Adjustment
    2. Proposed and Final Changes
    a. Process for Recognizing IOLs as Belonging to an Active IOL 
Class
    b. Public Notice and Comment Regarding Adjustments of NTIOL 
Payment Amounts
    c. Factors CMS Considers in Determining Whether an Adjustment of 
Payment for Insertion of a New Class of NTIOL is Appropriate
    d. Revision of the Content of a Request to Review
    e. Notice of CMS Determination
    f. Payment Adjustment
    G. Announcement of CY 2007 Deadline for Submitting Requests for 
CMS Review of Appropriateness of ASC Payment for Insertion Following 
Cataract Surgery of an NTIOL
XVIII. Medicare Contracting Reform Mandate
    A. Background
    B. CMS's Vision for Medicare Fee-for-Service and Medicare 
Administrative Contractors (MAC)
    C. Provider Nomination and the Former Medicare Acquisition 
Authorities
    D. Summary of Changes Made to Section 1816 of the Act
    E. Provisions of the Proposed and Final Regulations
    1. Definitions
    2. Assignments of Providers and Suppliers to MACs
    3. Other Technical and Conforming Changes
    a. Definition of ``Intermediary''
    b. Intermediary Functions
    c. Options Available to Providers and CMS
    d. Nomination for Intermediary
    e. Notification of Actions on Nominations, Changes to Another 
Intermediary or to Direct Payment, and Requirements for Approval of 
an Agreement
    f. Considerations Relating to the Effective and Efficient 
Administration of the Medicare Program
    g. Assignment and Reassignment of Providers by CMS
    h. Designation of National or Regional Intermediaries and 
Designation of Regional and Alternative Designated Regional 
Intermediaries for Home Health Agencies and Hospices
    i. Awarding of Experimental Contracts
XIX. Reporting Quality Data for Improved Quality and Costs under the 
OPPS
XX. Promoting Effective Use of Health Information Technology
XXI. Health Care Information Transparency Initiative
XXII. Additional Quality Measures and Procedures for Hospital 
Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update
    A. Background
    B. Additional Quality Measures for FY 2008
    1. Introduction
    2. HCAHPS Survey and the Hospital Quality Initiative
    3. Surgical Care Improvement Project (SCIP) Quality Measures
    4. Mortality Outcome Measures
    C. General Procedures and Participation Requirements for the FY 
2008 IPPS RHQDAPU Program
    D. HCAHPS Procedures and Participation Requirements for the FY 
2008 IPPS RHQDAPU Program
    1. Introduction
    2. HCAHPS Hospital Pledge and Beginning Date for Data Collection
    3. HCAHPS Dry Run
    4. HCAHPS Data Collection Requirements
    5. HCAHPS Registration Requirements
    6. Additional Steps for HCAHPS Participation
    7. HCAHPS Survey Completion Requirements
    8. HCAHPS Public Reporting
    9. Reporting HCAHPS Results for Multi-Campus Hospitals
    E. SCIP & Mortality Measure Requirements for the FY 2008 RHQDAPU 
Program
    F. Conclusion
XXIII. Files Available to the Public Via the Internet
XXIV. Collection of Information Requirements
XXV. Response to Comments
XXVI. Regulatory Impact Analysis
    A. Overall Impact
    1. Executive Order 12866
    2. Regulatory Flexibility Act (RFA)
    3. Small Rural Hospitals
    4. Unfunded Mandates
    5. Federalism
    B. Effects of OPPS Changes in This Final Rule with Comment 
Period
    1. Alternatives Considered
    a. Alternatives Considered for Coding and Payment Policy for 
Visits
    b. Alternatives Considered for Brachytherapy Source Payments
    c. Alternatives Considered for Payment of Radiopharmaceuticals
    2. Limitation of Our Analysis
    3. Estimated Impact of This Final Rule with Comment Period on 
Hospitals
    4. Estimated Effect of This Final Rule with Comment Period on 
Beneficiaries
    5. Conclusion
    6. Accounting Statement
    C. Effects of Changes to the ASC Payment System for CY 2007
    1. Alternatives Considered
    2. Limitations on Our Analysis
    3. Estimated Effects of This Final Rule with Comment Period on 
ASCs
    4. Estimated Effects of This Final Rule with Comment Period on 
Beneficiaries
    5. Conclusion
    6. Accounting Statement
    D. Effects of the Medicare Contracting Reform Mandate
    E. Effects of Additional Quality Measures and Procedures for 
Hospital Reporting of Quality Data for IPPS FY 2008
    1. Alternatives Considered
    2. Estimated Effects of This Final Rule with Comment Period
    a. Effects on Hospitals
    b. Effects on Other Providers
    c. Effects on the Medicare and Medicaid Program
    F. Executive Order 12866

Regulation Text

Addenda

Addendum A--OPPS List of Ambulatory Payment Classification (APCs) 
with Status Indicators (SI), Relative Weights, Payment Rates, and 
Copayment Amounts--CY 2007
Addendum AA--List of Medicare Approved ASC Procedures for CY 2007 
With Additions and Payment Rates; Including Rates That Result From 
Implementation of Section 5103 of the DRA
Addendum B--OPPS Payment Status By HCPCS Code and Related 
Information CY 2007
Addendum D1--Payment Status Indicators
Addendum D2--Comment Indicators
Addendum E--CPT Codes That Are Paid Only As Inpatient Procedures
Addendum L--Out-Migration Adjustment

I. Background for the OPPS

A. Legislative and Regulatory Authority for the Hospital Outpatient 
Prospective Payment System

    When the Medicare statute was originally enacted, Medicare payment 
for hospital outpatient services was based on hospital-specific costs. 
In an effort to ensure that Medicare and its beneficiaries pay 
appropriately for services and to encourage more efficient delivery of 
care, the Congress mandated replacement of the reasonable cost-based 
payment methodology with a prospective payment system (PPS). The 
Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33), added section 
1833(t)

[[Page 67965]]

to the Social Security Act (the Act) authorizing implementation of a 
PPS for hospital outpatient services (OPPS).
    The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act 
(BBRA) of 1999 (Pub. L. 106-113), made major changes in the hospital 
OPPS. The Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act (BIPA) of 2000 (Pub. L. 106-554), made further changes 
in the OPPS. Section 1833(t) of the Act was also amended by the 
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 
2003 (Pub. L. 108-173). The Deficit Reduction Act (DRA) of 2005 (Pub. 
L. 109-171), enacted on February 8, 2006, made additional changes in 
the OPPS. A discussion of the provisions contained in Pub. L. 109-171 
that are specific to the calendar year (CY) 2007 OPPS is included in 
section II.F. of this preamble.
    The OPPS was first implemented for services furnished on or after 
August 1, 2000. Implementing regulations for the OPPS are located at 42 
CFR Part 419.
    Under the OPPS, we pay for hospital outpatient services on a rate-
per-service basis that varies according to the ambulatory payment 
classification (APC) group to which the service is assigned. We use 
Healthcare Common Procedure Coding System (HCPCS) codes (which include 
certain Current Procedural Terminology (CPT) codes) and descriptors to 
identify and group the services within each APC group. The OPPS 
includes payment for most hospital outpatient services, except those 
identified in section I.B. of this preamble. Section 1833(t)(1)(B)(ii) 
of the Act provides for Medicare payment under the OPPS for hospital 
outpatient services designated by the Secretary (which includes partial 
hospitalization services furnished by community mental health centers 
(CMHCs)) and hospital outpatient services that are furnished to 
inpatients who have exhausted their Part A benefits or who are 
otherwise not in a covered Part A stay. Section 611 of Pub. L. 108-173 
added provisions for Medicare coverage of an initial preventive 
physical examination, subject to the applicable deductible and 
coinsurance, as an outpatient department service, payable under the 
OPPS.
    The OPPS rate is an unadjusted national payment amount that 
includes the Medicare payment and the beneficiary copayment. This rate 
is divided into a labor-related amount and a nonlabor-related amount. 
The labor-related amount is adjusted for area wage differences using 
the inpatient hospital wage index value for the locality in which the 
hospital or CMHC is located.
    All services and items within an APC group are comparable 
clinically and with respect to resource use (section 1833(t)(2)(B) of 
the Act). In accordance with section 1833(t)(2) of the Act, subject to 
certain exceptions, services and items within an APC group cannot be 
considered comparable with respect to the use of resources if the 
highest median (or mean cost, if elected by the Secretary) for an item 
or service in the APC group is more than 2 times greater than the 
lowest median cost for an item or service within the same APC group 
(referred to as the ``2 times rule''). In implementing this provision, 
we use the median cost of the item or service assigned to an APC group.
    Special payments under the OPPS may be made for new technology 
items and services in one of two ways. Section 1833(t)(6) of the Act 
provides for temporary additional payments which we refer to as 
``transitional pass-through payments'' for at least 2 but not more than 
3 years for certain drugs, biological agents, brachytherapy devices 
used for the treatment of cancer, and categories of other medical 
devices. For new technology services that are not eligible for 
transitional pass-through payments and for which we lack sufficient 
data to appropriately assign them to a clinical APC group, we have 
established special APC groups based on costs, which we refer to as new 
technology APCs. These new technology APCs are designated by cost bands 
which allow us to provide appropriate and consistent payment for 
designated new procedures that are not yet reflected in our claims 
data. Similar to pass-through payments, an assignment to a new 
technology APC is temporary; that is, we retain a service within a new 
technology APC until we acquire sufficient data to assign it to a 
clinically appropriate APC group.

B. Excluded OPPS Services and Hospitals

    Section 1833(t)(1)(B)(i) of the Act authorizes the Secretary to 
designate the hospital outpatient services that are paid under the 
OPPS. While most hospital outpatient services are payable under the 
OPPS, section 1833(t)(1)(B)(iv) of the Act excludes payment for 
ambulance, physical and occupational therapy, and speech-language 
pathology services, for which payment is made under a fee schedule. 
Section 614 of Pub. L. 108-173 amended section 1833(t)(1)(B)(iv) of the 
Act to exclude OPPS payment for screening and diagnostic mammography 
services. The Secretary exercised the authority granted under the 
statute to exclude from the OPPS those services that are paid under fee 
schedules or other payment systems. Such excluded services include, for 
example, the professional services of physicians and nonphysician 
practitioners paid under the Medicare Physician Fee Schedule (MPFS); 
laboratory services paid under the clinical diagnostic laboratory fee 
schedule; services for beneficiaries with end-stage renal disease 
(ESRD) that are paid under the ESRD composite rate; and, services and 
procedures that require an inpatient stay that are paid under the 
hospital inpatient prospective payment system (IPPS). We set forth the 
services that are excluded from payment under the OPPS in Sec.  419.22 
of the regulations.
    Under Sec.  419.20(b) of the regulations, we specify the types of 
hospitals and entities that are excluded from payment under the OPPS. 
These excluded entities include Maryland hospitals, but only for 
services that are paid under a cost containment waiver in accordance 
with section 1814(b)(3) of the Act; critical access hospitals (CAHs); 
hospitals located outside of the 50 States, the District of Columbia, 
and Puerto Rico; and Indian Health Service hospitals.

C. Prior Rulemaking

    On April 7, 2000, we published in the Federal Register a final rule 
with comment period (65 FR 18434) to implement a prospective payment 
system for hospital outpatient services. The hospital OPPS was first 
implemented for services furnished on or after August 1, 2000. Section 
1833(t)(9) of the Act requires the Secretary to review certain 
components of the OPPS not less often than annually and to revise the 
groups, relative payment weights, and other adjustments to take into 
account changes in medical practice, changes in technology, and the 
addition of new services, new cost data, and other relevant information 
and factors.
    Since initially implementing the OPPS, we have published final 
rules in the Federal Register annually to implement statutory 
requirements and changes arising from our experience with this system. 
We last published such a document on November 10, 2005 (70 FR 68516). 
In that final rule with comment period, we revised the OPPS to update 
the payment weights and conversion factor for services payable under 
the CY 2006 OPPS on the basis of claims data from January 1, 2004, 
through December 31, 2004, and to implement certain provisions of Pub. 
L. 108-173. In addition, we responded to public comments received on 
the provisions of November 15, 2004 final rule with comment period 
pertaining to

[[Page 67966]]

the APC assignment of HCPCS codes identified in Addendum B of that rule 
with the new interim (NI) comment indicators; and public comments 
received on the July 25, 2005 OPPS proposed rule for CY 2006 (70 FR 
42674).
    We published a correction of the November 10, 2005 final rule with 
comment period on December 23, 2005 (70 FR 76176). This correction 
document corrected a number of technical errors that appeared in the 
November 10, 2005 final rule with comment period.

D. APC Advisory Panel

1. Authority of the APC Panel
    Section 1833(t)(9)(A) of the Act, as amended by section 201(h) of 
the BBRA, requires that we consult with an outside panel of experts to 
review the clinical integrity of the payment groups and their weights 
under the OPPS. The Act further specifies that the panel will act in an 
advisory capacity. The Advisory Panel on Ambulatory Payment 
Classification (APC) Groups (the APC Panel), discussed under section 
I.D.2. of this preamble, fulfills these requirements. The APC Panel is 
not restricted to using data compiled by CMS and may use data collected 
or developed by organizations outside the Department in conducting its 
review.
2. Establishment of the APC Panel
    On November 21, 2000, the Secretary signed the initial charter 
establishing the APC Panel. This expert panel, which may be composed of 
up to 15 representatives of providers subject to the OPPS (currently 
employed full-time, not as consultants, in their respective areas of 
expertise), reviews and advises CMS about the clinical integrity of the 
APC groups and their weights. For purposes of this Panel, consultants 
or independent contractors are not considered to be full-time 
employees. The APC Panel is technical in nature and is governed by the 
provisions of the Federal Advisory Committee Act (FACA). Since its 
initial chartering, the Secretary has twice renewed the APC Panel's 
charter: on November 1, 2002, and on November 1, 2004. The current 
charter indicates, among other requirements, that the APC Panel 
continues to be technical in nature; is governed by the provisions of 
the FACA; may convene up to three meetings per year; has a Designated 
Federal Officer (DFO); and is chaired by a Federal official who also 
serves as a CMS medical officer.
    The current APC Panel membership and other information pertaining 
to the Panel, including its charter, Federal Register notices, meeting 
dates, agenda topics, and meeting reports can be viewed on the CMS Web 
site at http://www.cms.hhs.gov/FACA/ 05AdvisoryPanelonAmbulatory 
PaymentClassification Groups.as#TopOFPage.
3. APC Panel Meetings and Organizational Structure
    The APC Panel first met on February 27, February 28, and March 1, 
2001. Since that initial meeting, the APC Panel has held 10 subsequent 
meetings, with the last meeting taking place on August 23 and 24, 2006. 
(The APC Panel did not meet on August 25, 2006, as announced in the 
meeting notice published on June 23, 2006 (71 FR 36118).) Prior to each 
meeting, we publish a notice in the Federal Register to announce the 
meeting and, when necessary, to solicit and announce nominations for 
APC Panel membership.
    The APC Panel has established an operational structure that, in 
part, includes the use of three subcommittees to facilitate its 
required APC review process. The three current subcommittees are the 
Data Subcommittee, the Observation Subcommittee, and the Packaging 
Subcommittee. The Data Subcommittee is responsible for studying the 
data issues confronting the APC Panel and for recommending options for 
resolving them. The Observation Subcommittee reviews and makes 
recommendations to the APC Panel on all issues pertaining to 
observation services paid under the OPPS, such as coding and 
operational issues. The Packaging Subcommittee studies and makes 
recommendations on issues pertaining to services that are not 
separately payable under the OPPS, but are bundled or packaged APC 
payments. Each of these subcommittees was established by a majority 
vote of the APC Panel during a scheduled APC Panel meeting and their 
continuation as subcommittees was approved at the August 2006 APC Panel 
meeting. All subcommittee recommendations are discussed and voted upon 
by the full APC Panel.
    Discussions of the recommendations resulting from the APC Panel's 
March 2006 and August 2006 meetings are included in the sections of 
this preamble that are specific to each recommendation. For discussions 
of earlier APC Panel meetings and recommendations, we reference 
previous hospital OPPS final rules or the Web site mentioned earlier in 
this section.

E. Provisions of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003

    The Medicare Prescription Drug, Improvement, and Modernization Act 
(MMA) of 2003, Pub. L. 108-173, made changes to the Act relating to the 
Medicare OPPS. In the January 6, 2004 interim final rule with comment 
period and the November 15, 2004 final rule with comment period, we 
implemented provisions of Pub. L. 108-173 relating to the OPPS that 
were effective for services provided in CY 2004 and CY 2005, 
respectively. In the November 10, 2005 final rule with comment period, 
we implemented provisions of Pub. L. 108-173 relating to the OPPS that 
went into effect for services provided in CY 2006 (70 FR 68521). We 
note below those provision of Pub. L. 108-173 that will expire at the 
end of CY 2006.
1. Reduction in Threshold for Separate APCs for Drugs
    Section 621(a)(2) of Pub. L. 108-173 amended section 1833(t)(16) of 
the Act to set a threshold of $50 per administration for the 
establishment of separate APCs for drugs and biologicals furnished from 
January 1, 2005, through December 31, 2006. Because this statutory 
provision will no longer be in effect for CY 2007, we have included in 
section V. of this preamble a discussion of the methodology that we 
will use to determine a threshold for establishing separate APCs for 
drugs and biologicals for CY 2007.
2. Special Payment for Brachytherapy
    Section 621(b)(1) of Pub. L. 108-173 amended section 1833(t)(16) of 
the Act to require that payment for brachytherapy devices consisting of 
a seed or seeds (or radioactive source) furnished on or after January 
1, 2004, and before January 1, 2007, be paid based on the hospital's 
charge for each device furnished, adjusted to cost. Because this 
statutory provision will no longer be in effect for CY 2007, we discuss 
our methodology for payment for brachytherapy devices for CY 2007 in 
section VII.B. of this preamble.

F. Provisions of the Deficit Reduction Act (DRA) of 2005

    The Deficit Reduction Act (DRA) of 2005, Pub. L. 109-171, enacted 
on February 8, 2006, included three provisions affecting the OPPS, as 
discussed below.
1. 3-Year Transition of Hold Harmless Payments
    Section 5105 of Pub. L. 109-171 provides a 3-year transition of 
hold harmless OPPS payments for hospitals

[[Page 67967]]

located in a rural area with not more than 100 beds that are not 
defined as sole community hospitals (SCHs). This provision provides an 
increased payment for such hospitals for covered OPD services furnished 
on or after January 1, 2006, and before January 1, 2009, if the OPPS 
payment they receive is less than the pre-BBA payment amount that they 
would have received for the same covered OPD services. This provision 
specifies that, in such cases, the amount of payment to the specified 
hospitals shall be increased by the applicable percentage of such 
difference. Section 5105 specifies the applicable percentage as 95 
percent for CY 2006, 90 percent for CY 2007, and 85 percent for CY 
2008. This provision is discussed in section II.F.1. of the preamble.
2. Medicare Coverage of Ultrasound Screening for Abdominal Aortic 
Aneurysms (AAAs)
    Section 5112 of Pub. L. 109-171 amended section 1861 of the Act to 
include coverage of ultrasound screening for abdominal aortic aneurysms 
for certain individuals on or after January 1, 2007. The provision will 
apply to individuals (a) who receive a referral for such an ultrasound 
screening as a result of an initial preventive physical examination; 
(b) who have not been previously furnished with an ultrasound screening 
under Medicare; and (c) who have a family history of abdominal aortic 
aneurysm or manifest risk factors included in a beneficiary category 
recommended for screening (as determined by the United States 
Preventive Services Task Force). Ultrasound screening for abdominal 
aortic aneurysm will be included in the initial preventive physical 
examination. Section 5112 also added ultrasound screening for abdominal 
aortic aneurysm to the list of services for which the beneficiary 
deductible does not apply. These amendments apply to services furnished 
on or after January 1, 2007. See section XIII.B. of this preamble for a 
detailed discussion of this provision.
3. Colorectal Cancer Screening
    Section 5113 of Pub. L. 109-171 amended section 1833(b) of the Act 
to add colorectal cancer screening to the list of services for which 
the beneficiary deductible does not apply. This provision applies to 
services furnished on or after January 1, 2007. See the Medicare 
Physician Fee Schedule (MPFS) CY 2007 final rule for a detailed 
discussion of this provision.

G. Summary of the Provisions of the CY 2007 OPPS Proposed Rule

    On August 23, 2006, we published a proposed rule in the Federal 
Register (71 FR 49506) that set forth proposed changes to the Medicare 
hospital OPPS for CY 2007 to implement statutory requirements and 
changes arising from our continuing experience with the system and to 
implement certain provisions of Pub. L. 109-171 specified in sections 
II.F.1. and XIII.B. of this preamble. We also proposed to revise the 
standard for critical access hospital personnel that are allowed to 
perform emergency medical screenings. In addition, we proposed changes 
to the Medicare ASC payment system for CY 2007 and CY 2008 and to the 
way we process fee-for-service (FFS) claims under Medicare Part A and 
Part B.
    Finally, we set forth a proposed rule seeking comments on the 
RHQDAPU program under the Medicare hospital IPPS for FY 2008. These 
changes will be effective for payments beginning with FY 2008. The 
following is a summary of the major changes included in the CY 2007 
OPPS proposed rule:
1. Updates to the OPPS' Payments for CY 2007
    In the proposed rule, we set forth--
     The methodology used to recalibrate the proposed APC 
relative payment weights and the proposed median costs for CY 2007.
     The proposed payment for partial hospitalization, 
including the proposed separate threshold for outlier payments for 
CMHCs.
     The proposed update to the conversion factor used to 
determine payment rates under the OPPS for CY 2007.
     The proposed retention of our current policy to apply the 
IPPS wage indices to wage adjust the APC median costs in determining 
the OPPS payment rate and the copayment standardized amount for CY 
2007.
     The proposed update of statewide average default cost-to-
charge ratios.
     Proposed changes relating to the hold harmless payment 
provision and Sec.  419.70(d).
     Proposed changes relating to payment for rural SCHs, 
including Essential Access Community Hospitals (EACHs) for CY 2007.
     The proposed retention of our current policy for 
calculating hospital outpatient outlier payments for CY 2007.
     Calculation of the proposed national unadjusted Medicare 
OPPS payment.
     The proposed beneficiary copayment for OPPS services for 
CY 2007.
2. Ambulatory Payment Classification (APC) Group Policies
    In the proposed rule, we discussed establishing a number of new 
APCs and making changes to the assignment of HCPCS codes under a number 
of existing APCs based on our analyses of Medicare claims data and 
recommendations of the APC Panel. We also discussed the application of 
the 2 times rule and proposed exceptions to it; proposed changes for 
specific APCs; proposed movement of procedures from the New Technology 
APCs; and the proposed additions of new procedure codes to the APC 
groups.
3. Payment Changes for Devices
    In the proposed rule, we discussed proposed changes to the device-
dependent APCs and to payment for pass-through devices. We also 
discussed the proposed payment policy for devices that are replaced 
without cost or credit to the hospital for a replaced device and the 
proposed related regulation under Sec.  419.45.
4. Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals
    In the proposed rule, we discussed proposed payment changes for 
drugs, biologicals, and radiopharmaceuticals.
5. Estimate of Transitional Pass-Through Spending in CY 2007 for Drugs, 
Biologicals, and Devices
    In the proposed rule, we discussed the proposed methodology for 
estimating total pass-through spending and whether there should be a 
pro rata reduction for transitional pass-through drugs, biologicals, 
radiopharmaceuticals, and categories of devices for CY 2007.
6. Brachytherapy Payment Changes
    In the proposed rule, we included a discussion of our proposal 
concerning coding and payment for the sources of brachytherapy.
7. Coding and Payment for Drugs Administration
    In the proposed rule, we discussed our proposed coding and payment 
changes for drug administration services.
8. Hospital Coding and Payments for Visits
    In the proposed rule, we discussed our analyses of various 
guidelines for coding hospital visits and the proposed HCPCS codes and 
payment policy for those visits.

[[Page 67968]]

9. Payment for Blood and Blood Products
    In the proposed rule, we discussed our proposed criteria and coding 
changes for the blood and blood products.
10. Payment for Observation Services
    In the proposed rule, we discussed our proposed continuation of 
applying the criteria for separate payment for observation services and 
the coding methodology for observation services implemented in CY 2006.
11. Procedures That Will Be Paid Only as Inpatient Services
    In the proposed rule, we discussed the procedures that we proposed 
to remove from the inpatient list and assign to APCs.
12. Nonrecurring Policy Changes
    In the proposed rule, we discussed a proposed technical change to 
Sec.  419.21(d) of the regulations related to Comprehensive Outpatient 
Rehabilitation Facility (CORF) services and proposed coding and payment 
for ultrasound screening for abdominal aortic aneurysms (AAAs) as a new 
service paid under the OPPS in CY 2007.
13. Emergency Medical Screening in Critical Access Hospitals (CAHs)
    In the proposed rule, we discussed our proposal to revise Sec.  
485.618(d) of the regulations pertaining to the standards for critical 
access hospital personnel available to perform emergency medical 
screening services.
14. Payment Status and Comment Indicator Assignments
    In the proposed rule, we discussed our list of status indicators 
assigned to APCs and presented our comment indicators that we proposed 
to use in this final rule with comment period.
15. OPPS Policy and Payment Recommendations
    In the proposed rule, we addressed recommendations made by MedPAC, 
the APC Panel, and the GAO regarding the OPPS for CY 2007.
16. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 2007
    In the proposed rule, we discussed changes to the ASC list of 
covered procedures for CY 2007; implementation of section 5103 of Pub. 
L. 108-173; our proposal for modifying the current ASC process for 
adjusting payment for new technology intraocular lenses; and related 
regulatory changes.
17. Revised ASC Payment System for Implementation January 1, 2008
    In the proposed rule, we set forth our proposal to revise the 
current ASC payment system in accordance with Pub. L. 108-173, 
effective January 1, 2008. We note that we are not finalizing this 
proposal in this final rule with comment period. Rather, we will issue 
a separate document in the Federal Register that will address public 
comments received and finalize the ASC payment system effective January 
1, 2008.
18. Medicare Contracting Reform Mandate
    In the proposed rule, we set forth changes to the way we process 
FFS claims under Medicare Part A and Part B.
19. Reporting Quality Data for Improved Quality and Costs Under the 
OPPS
    In the proposed rule, we proposed to adapt the quality improvement 
mechanism provided by the IPPS RHQDAPU program for use under the OPPS.
20. Promoting Effective Use of Health Information Technology
    In the proposed rule, we discussed our plans to promote and adopt 
effective use of health information technology to improve the quality 
of care for Medicare beneficiaries.
21. Health Care Information Transparency Initiative
    In the proposed rule, we announced our plans to launch a major 
health care transparency initiative in 2006.
22. Additional Quality Measures and Procedures for Hospital Reporting 
of Quality Data for FY 2008 IPPS Annual Payment Update
    In the proposed rule, we discussed our proposal to expand the IPPS 
Reporting Hospital Quality Data for Annual Payment program measurement 
set for FY 2008 beyond the measures adopted for the FY 2007 IPPS 
update.
23. Impact Analysis
    In the proposed rule, we set forth an analysis of the impact that 
the proposed changes will have on affected entities and beneficiaries.

H. Public Comments Received in Response to the CY 2007 OPPS Proposal 
Rule and on the Reporting Hospital Quality Data for FY 2008 IPPS Annual 
Payment Update Program--HCAHPS Survey, SCIP, and Mortality Proposed 
Rule

    We received approximately 1,100 timely items of correspondence 
containing multiple comments on the CY 2007 OPPS proposed rule. We note 
that we received some comments that were outside of the scope of the CY 
2007 OPPS proposed rule. These comments are not addressed in the CY 
2007 final rule. We also received approximately 20 timely items of 
correspondence on Reporting Hospital Quality Data for FY 2008 Inpatient 
Prospective Payment System Annual Payment Update Program--HCAHPS 
Survey, SCIP, and Mortality proposed rule. Summaries of the public 
comments and our responses to those comments are set forth under the 
appropriate headings.

I. Public Comments Received on the November 10, 2005 OPPS Final Rule 
with Comment Period

    We received approximately 41 timely items of correspondence on the 
November 10, 2005 OPPS final rule with comment period, some of which 
contained multiple comments on the APC assignment of HCPCS codes 
identified with the NI comment indicator in Addendum B of that final 
rule with comment period. Summaries of those public comments and our 
responses to those comments are set forth in the various sections under 
the appropriate headings.

II. Updates Affecting OPPS Payments for CY 2007

A. Recalibration of APC Relative Weights for CY 2007

1. Database Construction
a. Database Source and Methodology
    Section 1833(t)(9)(A) of the Act requires that the Secretary review 
and revise the relative payment weights for APCs at least annually. In 
the April 7, 2000 OPPS final rule with comment period (65 FR 18482), we 
explained in detail how we calculated the relative payment weights that 
were implemented on August 1, 2000, for each APC group. Except for some 
reweighting due to a small number of APC changes, these relative 
payment weights continued to be in effect for CY 2001. This policy is 
discussed in the November 13, 2000 interim final rule (65 FR 67824 
through 67827).

[[Page 67969]]

    In the CY 2007 OPPS proposed rule, we proposed to use the same 
basic methodology that we described in the April 7, 2000 final rule 
with comment period to recalibrate the APC relative payment weights for 
services furnished on or after January 1, 2007, and before January 1, 
2008. That is, we would recalibrate the relative payment weights for 
each APC based on claims and cost report data for outpatient services. 
We proposed to use the most recent available data to construct the 
database for calculating APC group weights. For the purpose of 
recalibrating the APC relative payment weights for CY 2007, we used 
approximately 142.5 million final action claims for hospital OPD 
services furnished on or after January 1, 2005, and before January 1, 
2006. Of the 142.5 million final action claims for services provided in 
hospital outpatient settings, 110.2 million claims were of the type of 
bill potentially appropriate for use in setting rates for OPPS services 
(but did not necessarily contain services payable under the OPPS). Of 
the 110.2 million claims, approximately 51.7 million were not for 
services paid under the OPPS or were excluded as not appropriate for 
use (for example, erroneous cost-to-charge ratios or no HCPCS codes 
reported on the claim). We were able to use 54.1 million whole claims 
of the remaining 58.5 million claims to set the OPPS APC relative 
weights for CY 2007 OPPS. From the 54.1 million whole claims, we 
created 98.5 million single records, of which 68.5 million were 
``pseudo'' single claims (created from multiple procedure claims using 
the process we discuss in this section).
    As proposed, the final APC relative weights and payments for CY 
2007 in Addenda A and B to this final rule with comment period were 
calculated using claims from this period that had been processed before 
June 30, 2006, and continue to be based on the median hospital costs 
for services in the APC groups. We selected claims for services paid 
under the OPPS and matched these claims to the most recent cost report 
filed by the individual hospitals represented in our claims data.
    Comment: Several commenters supported the use of the most recent 
claims and cost report data to calculate the median costs for use in 
the CY 2007 OPPS.
    Response: We appreciate the commenters' support and have used the 
claims for services paid under the CY 2005 OPPS as processed through 
the common working file as of June 30, 2006, in the calculation of the 
median costs on which the CY 2007 OPPS rates are based. In addition, we 
have used the most recently submitted cost report data as reported to 
the HCRIS system as of June 30, 2006, to calculate the cost-to-charge 
ratios (CCRs) used to reduce the billed charges to costs for purposes 
of calculating the median costs on which the CY 2007 OPPS rates are 
based.
    After carefully considering all comments received, we are 
finalizing our data source and methodology for the recalibration of CY 
2007 APC relative payment weights as proposed without modification, as 
described in this section.
b. Use of Single and Multiple Procedure Claims
    For CY 2007, we proposed to continue to use single procedure claims 
to set the medians on which the APC relative payment weights would be 
based. We have received many requests asking that we ensure that the 
data from claims that contain charges for multiple procedures are 
included in the data from which we calculate the relative payment 
weights. Requesters believe that relying solely on single procedure 
claims to recalibrate APC relative payment weights fails to take into 
account data for many frequently performed procedures, particularly 
those commonly performed in combination with other procedures. They 
believe that, by depending upon single procedure claims, we base 
relative payment weights on the least costly services, thereby 
introducing downward bias to the medians on which the weights are 
based.
    We agree that, optimally, it is desirable to use the data from as 
many claims as possible to recalibrate the APC relative payment 
weights, including those with multiple procedures. We generally use 
single procedure claims to set the median costs for APCs because we 
are, so far, unable to ensure that packaged costs can be appropriately 
allocated across multiple procedures performed on the same date of 
service. However, by bypassing specified codes that we believe do not 
have significant packaged costs, we are able to use more data from 
multiple procedure claims. In many cases, this enables us to create 
multiple ``pseudo'' single claims from claims that, as submitted, 
contained multiple separately paid procedures on the same claim. For 
the CY 2007 OPPS, we proposed to use the date of service on the claims 
and a list of codes to be bypassed to create ``pseudo'' single claims 
from multiple procedure claims, as we did in recalibrating the CY 2006 
APC relative payment weights. We refer to these newly created single 
procedure claims as ``pseudo'' single claims because they were 
submitted by providers as multiple procedure claims.
    For CY 2003, we created ``pseudo'' single claims by bypassing HCPCS 
codes 93005 (Electrocardiogram, tracing), 71010 (Chest x-ray), and 
71020 (Chest x-ray) on a submitted claim. However, we did not use 
claims data for the bypassed codes in the creation of the median costs 
for the APCs to which these three codes were assigned because the level 
of packaging that would have remained on the claim after we selected 
the bypass code was not apparent and, therefore, it was difficult to 
determine if the medians for these codes would be correct.
    For CY 2004, we created ``pseudo'' single claims by bypassing these 
three codes and also by bypassing an additional 269 HCPCS codes in 
APCs. We selected these codes based on a clinical review of the 
services and because it was presumed that these codes had only very 
limited packaging and could appropriately be bypassed for the purpose 
of creating ``pseudo'' single claims. The APCs to which these codes 
were assigned were varied and included mammography, cardiac 
rehabilitation, and Level I plain film x-rays. To derive more 
``pseudo'' single claims, we also split the claims where there were 
dates of service for revenue code charges on that claim that could be 
matched to a single procedure code on the claim on the same date.
    For the CY 2004 OPPS, as in CY 2003, we did not include the claims 
data for the bypassed codes in the creation of the APCs to which the 
269 codes were assigned because, again, we had not established that 
such an approach was appropriate and would aid in accurately estimating 
the median costs for those APCs. For CY 2004, from approximately 16.3 
million otherwise unusable claims, we used approximately 9.5 million 
multiple procedure claims to create approximately 27 million ``pseudo'' 
single claims. For CY 2005, we identified 383 bypass codes and from 
approximately 24 million otherwise unusable claims, we used 
approximately 18 million multiple procedure claims to create 
approximately 52 million ``pseudo'' single claims. For CY 2005, we used 
the claims data for the bypass codes combined with the single procedure 
claims to set the median costs for the bypass codes.
    For CY 2006, we continued using the codes on the CY 2005 OPPS 
bypass list and expanded it to include 404 bypass codes, including 3 
bladder catheterization codes (CPT codes 51701, 51702, and 51703), 
which did not meet the empirical criteria discussed below for the 
selection of bypass codes. We added these three codes to the CY 2006

[[Page 67970]]

bypass list because a decision to change their payment status from 
packaged to separately paid would have resulted in a reduction of the 
number of single bills on which we could base median costs for other 
major separately paid procedures that were billed on the same claim 
with these three procedure codes. That is, single bills which contained 
other procedures would have become multiple procedure claims when these 
bladder catheterization codes were converted to separately paid status. 
We believed and continue to believe that bypassing these three codes 
does not adversely affect the medians for other procedures because we 
believe that when these services are performed on the same day as 
another separately paid service, any packaging that appears on the 
claim would be appropriately associated with the other procedure and 
not with these codes.
    Consequently, for CY 2006, we identified 404 bypass codes for use 
in creating ``pseudo'' single claims and used some part of 90 percent 
of the total claims that were eligible for use in OPPS ratesetting and 
modeling in developing the final rule with comment period. This process 
enabled us to use, for the CY 2006 OPPS, 88 million single bills for 
ratesetting: 55 million ``pseudo'' singles and 34 million ``natural'' 
single bills (bills that were submitted containing only one separately 
payable major HCPCS code). (These numbers do not sum to 88 million 
because more than 800,000 single bills were removed when we trimmed at 
the HCPCS level at +/-3 standard deviations from the geometric mean.)
    For CY 2007, we proposed to continue using date-of-service matching 
as a tool for creation of ``pseudo'' single claims and to continue the 
use of a bypass list to create ``pseudo'' single claims. The process we 
proposed for the CY 2007 OPPS resulted in our being able to use some 
part of 92.6 percent of the total claims that are eligible for use in 
the OPPS ratesetting and modeling in developing this final rule with 
comment period. This process enabled us to use, for CY 2007, 68.5 
million ``pseudo'' singles and 31.6 million ``natural'' single bills.
    We proposed to bypass the 454 codes identified in Table 1 of the 
proposed rule (71 FR 49517) to create new single claims and to use the 
line-item costs associated with the bypass codes on these claims, 
together with the single procedure claims, in the creation of the 
median costs for the APCs into which they are assigned. Of the codes on 
this list, 404 codes were used for bypass in CY 2006. We proposed to 
continue the use of the codes on the CY 2006 OPPS bypass list and to 
expand it by adding codes that, using data presented to the APC Panel 
at its March 2006 meeting, meet the same empirical criteria as those 
used in CY 2006 to create the bypass list, or which our clinicians 
believe would contain minimal packaging if the services were correctly 
coded (for example, ultrasound guidance). (Bypass codes shown in Table 
1 with an asterisk indicated the HCPCS codes we proposed to add to the 
CY 2006 OPPS listed codes for bypass in CY 2007.) Our examination of 
the data against the criteria for inclusion on the bypass list, as 
discussed below for the addition of new codes, shows that the 
empirically selected codes used for bypass for the CY 2006 OPPS 
generally continue to meet the criteria or come very close to meeting 
the criteria, and we have received no comments against bypassing them.
    As proposed, the following empirical criteria that we used to 
determine the additional codes to add to the CY 2006 OPPS bypass list 
to create the bypass list for the CY 2007 OPPS were developed by 
reviewing the frequency and magnitude of packaging in the single claims 
for payable codes other than drugs and biologicals. We assumed that the 
representation of packaging on the single claims for any given code is 
comparable to packaging for that code in the multiple claims:
     There were 100 or more single claims for the code. This 
number of single claims ensured that observed outcomes were 
sufficiently representative of packaging that might occur in the 
multiple claims.
     Five percent or fewer of the single claims for the code 
had packaged costs on that single claim for the code. This criterion 
results in limiting the amount of packaging being redistributed to the 
payable procedure remaining on the claim after the bypass code is 
removed and ensures that the costs associated with the bypass code 
represent the cost of the bypassed service.
     The median cost of packaging observed in the single claims 
was equal to or less than $50. This limits the amount of error in 
redistributed costs.
     The code is not a code for an unlisted service.
    In addition, we proposed to add to the bypass list codes that our 
clinicians believe contain minimal packaging and codes for specified 
drug administration services for which hospitals have requested 
separate payment but for which it is not possible to acquire median 
costs unless we add these codes to the bypass list. A more complete 
discussion of the effects of adding these drug administration codes to 
the bypass list is contained in the discussion of drug administration 
payment changes in section VIII.C. of this preamble.
    In the CY 2007 OPPS proposed rule, we specifically invited public 
comment on the ``pseudo'' single process, including the bypass list and 
the criteria.
    Comment: The commenters urged CMS to continue to find ways to use 
all data from multiple procedure claims to set the median costs on 
which the payment rates are based. Many commenters supported the bypass 
list as a vehicle to enable use of all claims data. However, some 
commenters were concerned that placing HCPCS codes on the bypass list 
would lead to those codes being undervalued because no packaging from 
the multiple procedure bill is attributed to them. These commenters 
urged CMS to validate that these services were not being systematically 
undervalued by being bypassed and thus having many units of the service 
used for median setting with no attribution of packaging to the code. 
In many cases, the commenters did not offer specific discussion of what 
packaging they believe would be appropriately attached to the codes on 
the bypass list. One commenter suggested that CMS add CPT code 77421 
(Steroscopic X-ray guidance for localization of target volume for the 
delivery of radiation therapy) to secure more single procedure claims 
data for median setting. Another commenter asked that CMS add CPT code 
88307 (Level V-Surgical pathology, gross and microscopic examination) 
to the bypass list because it would be consistent with the inclusion of 
CPT codes 88304 (Level III-Surgical pathology, gross and microscopic 
examination) and 88305 (Level IV-Surgical pathology, gross and 
microscopic examination) on the bypass list.
    Response: We agree that the bypass list has been very useful in 
enabling us to use data from multiple procedure claims to set median 
costs for many services. The use of date of service stratification and 
the bypass list enabled us to create 68.5 million ``pseudo'' single 
claims that would not otherwise have been used to set median costs for 
the CY 2007 OPPS. However, we recognize that it is necessary to be 
cautious in this approach to minimize the possibility that we could 
mistakenly apply packaging on the claim to the wrong service. For that 
reason, each year we investigate the amount of packaging on natural 
single bills and consider whether changes should be made to the bypass 
list. However, in some cases, we know that the natural single bills are 
incorrect, and it is not

[[Page 67971]]

reasonable to base a decision on their level of packaging from what we 
believe are incorrectly coded claims. In these cases, we use clinical 
judgment to determine whether, on a correctly coded claim, the 
packaging would be associated with the code as defined or whether the 
packaging would more appropriately be associated with other procedures. 
For example, a single procedure bill for an ultrasound guidance service 
which is used only for guidance during an associated surgical procedure 
would not be correctly coded and therefore, clinically, we would not 
expect the packaged costs observed on these single claims to be 
correctly attributed to the guidance procedure. We believe that the 
ultrasound guidance procedure itself could not be the service that 
required the drugs, devices, or operating room use that would usually 
also be billed on a correctly coded claim. In these cases, we would 
place the ultrasound guidance procedure on the bypass list and 
attribute the packaged costs that appear on the same claim to the 
surgical procedure on the claim.
    We have been actively investigating options for using all claims 
data in the establishment of median costs, and we intend to be ready to 
discuss our findings in the CY 2008 OPPS proposed rule. With respect to 
the suggestions for additions to the bypass list, we will evaluate the 
potential for adding CPT codes 77421 and 88307 to the bypass list for 
purposes of the CY 2008 OPPS ratesetting.
    Comment: One commenter asked that CMS use all claims data on 
multiple procedure claims by allocating the packaging on a claim with 
multiple surgical procedures based on the currently existing relative 
weights to create ``pseudo'' single claims from all multiple procedure 
claims. The commenter suggested that if CMS is concerned about that 
process causing the weights being calculated to not reflect changes in 
cost, CMS might use this process only in cases in which the number of 
units for HCPCS codes on natural single bills are below some tolerance 
so that these claims would be used only on low volume procedures.
    Response: We are concerned that use of the current relative weights 
to allocate the packaging on multiple procedure claims may cause 
packaging to be allocated inappropriately in some cases. As we indicate 
above, we are continuing to explore ways that packaging could be 
allocated on multiple procedure claims in such a way that we would have 
confidence in the allocation.
    Comment: One commenter requested that CMS remove CPT code 76942 
(Ultrasonic guidance for needle placement (eg biopsy, aspiration, 
injection, localization device), imaging supervision and 
interpretation) from the bypass list, because the commenter believed it 
would raise the median cost for APC 0268, the APC where CPT code 76942 
is assigned for CY 2007. According to the commenter, the natural single 
claims for CPT code 76942 have a higher median cost than the ``pseudo'' 
single claims. The commenter indicated that when all packaged costs are 
removed from the natural singles, their median is close to the median 
for the ``pseudo'' single claims. If removing this code from the bypass 
list altogether results in too few ``pseudo'' single claims, the 
commenter requested that CMS calculate the median cost for APC 0268 
using only natural single claims.
    Response: We agree with the commenter that the median of APC 0268 
is higher with the exclusion of ``pseudo'' singles that are created 
from claims that include CPT code 76942 than it would be if we only 
used true single claims that include CPT code 76942. However, we 
believe that the single bills for CPT code 76942 are miscoded and, 
therefore, inappropriately attribute the procedural costs (for example, 
the needle placement for biopsy and injection) to ultrasound guidance 
rather than the biopsy or aspiration procedures. We note that CPT code 
76942 is the code with the highest frequency in APC 0268 and, 
therefore, contributes greatly to the median cost of the APC. The 
commenter provided no information regarding the specific packaging 
associated with CPT code 76942; therefore, we continue to believe that 
its inclusion on the bypass list, and the resulting calculation of the 
APC median cost for APC 0268, is appropriate.
    After carefully considering all public comments received on our 
proposal, we are adopting as final the proposed ``pseudo'' single 
process and the bypass codes listed in Table 1.
BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C

c. Revised Overall Cost-to-Charge Ratio (CCR) Calculation
    We calculate both an overall CCR and cost center-specific cost-to-
charge ratios (CCRs) for each hospital. For the CY 2007 OPPS, we 
proposed to change the methodology for calculating the overall CCR. The 
overall CCR is used in many components of the OPPS. We use the overall 
CCR to estimate costs from charges on a claim when we do not have an 
accurate cost center CCR. This does not happen very often. For the vast 
majority of services, we are able to use a cost center CCR to estimate 
costs from charges. However, we also use the overall CCR to identify 
the outlier threshold, to model payments for services that are paid at 
charges reduced to cost, and, during implementation, to determine 
outlier payments and payments for other services.
    As stated in the CY 2007 OPPS proposed rule (71 FR 49528), we have 
discovered that the calculation of the overall CCR that the fiscal 
intermediaries are using to determine outlier payments and payments for 
services paid at charges reduced to cost differs from the overall CCR 
that we use to model the OPPS. In Program Transmittal A-03-04 on 
``Calculating Provider-Specific Outpatient Cost-to-Charge Ratios (CCRs) 
and Instructions on Cost Report Treatment of Hospital Outpatient 
Services Paid on a Reasonable Cost Basis'' (January 17, 2003), we 
revised the overall CCR calculation that the fiscal intermediaries use 
in determining outlier and other cost payments. Until this point, each 
fiscal intermediary had used an overall CCR provided by CMS, or 
calculated an updated CCR at the provider's request using the same 
calculation. The calculation in Program Transmittal A-03-04, that is, 
the fiscal intermediary calculation, diverged from the ``traditional'' 
overall CCR that we used for modeling. It should be noted that the 
fiscal intermediary overall CCR calculation noted in Program 
Transmittal A-03-04 was created with feedback and input from the fiscal 
intermediaries.
    CMS' ``traditional'' calculation consists of summing the total 
costs from Worksheet B, Part I (Column 27), after removing the costs 
for nursing and paramedical education (Columns 21 and 24), for those 
ancillary cost centers that we believe contain most OPPS services, 
summing the total charges from Worksheet C, Part I (Columns 6 and 7) 
for the same set of ancillary cost centers, and dividing the former by 
the latter. We exclude selected ancillary cost centers from our overall 
CCR calculation, such as 5700 Renal Dialysis, because we believe that 
the costs and

[[Page 67984]]

charges in these cost centers are largely paid for under other payment 
systems. The specific list of ancillary cost centers, both standard and 
nonstandard, included in our overall CCR calculation is available on 
our Web site in the revenue center-to-cost center crosswalk workbook: 
http://www.cms.hhs.gov/HospitalOutpatientPPS.
    The overall CCR calculation provided in Program Transmittal A-03-
04, on the other hand, takes the CCRs from Worksheet C, Part I, Column 
9, for each specified ancillary cost center; multiplies them by the 
Medicare Part B outpatient specific charges in each corresponding 
ancillary cost center from Worksheet D, Part V (Columns 2, 3, 4, and 5 
and subscripts thereof); and then divides the sum of these costs by the 
sum of charges for the specified ancillary cost centers from Worksheet 
D, Part V (Columns 2, 3, 4, and 5 and subscripts thereof). The 
elimination of the reference to Part VI in this final rule with comment 
period is not a change from the proposed methodology. We used only data 
from Worksheet D, Part V of the HCRIS electronic cost report to 
calculate the overall CCRs for both the proposed rule and final rule 
with comment period. We previously referenced both Part V and Part VI 
in the proposed rule and in prior rules because both Part V and Part VI 
appear on the same page in Worksheet D on the paper cost report, 
although no data from Part VI on the electronic cost report were used 
in the calculation.
    Compared with our ``traditional'' overall CCR calculation that has 
been used for modeling OPPS and to calculate the median costs, this 
fiscal intermediary calculation of overall CCR fails to remove allied 
health costs and adds weighting by Medicare Part B charges.
    In comparing these two calculations, we discovered that, on 
average, the overall CCR calculation being used by the fiscal 
intermediaries resulted in higher overall CCRs than under our 
``traditional'' calculation. Using the most recent cost report data 
available for every provider with valid claims for CY 2004 as of 
November 2005, we estimated the median overall CCR using the 
traditional calculation to be 0.3040 (mean 0.3223) and the median 
overall CCR using the fiscal intermediary calculation to be 0.3309 
(mean 0.3742). There also was much greater variability in the fiscal 
intermediary calculation of the overall CCR. The standard deviation 
under the ``traditional'' calculation was 0.1318, while the standard 
deviation using the fiscal intermediary's calculation was 0.2143. In 
part, the higher median estimate for the fiscal intermediary 
calculation is attributable to the inclusion of allied health costs for 
the over 700 hospitals with allied health programs. It is inappropriate 
to include these costs in the overall CCR calculation, because CMS 
already reimburses hospitals for the costs of these programs through 
cost report settlement. The higher median estimate and greater 
variability also is a function of the weighting by Medicare Part B 
charges. Because the fiscal intermediary overall CCR calculation is 
higher, on average, CMS has underestimated the outlier payment 
thresholds and, therefore, overpaid outlier payments. We also have 
underestimated spending for services paid at charges reduced to cost in 
our budget neutrality estimates.
    In examining the two different calculations, we decided that 
elements of each methodology had merit. Clearly, as noted above, allied 
health costs should not be included in an overall CCR calculation. 
However, weighting by Medicare Part B charges from Worksheet D, Part V, 
makes the overall CCR calculation more specific to OPPS. Therefore, we 
proposed to adopt a single overall CCR calculation that incorporates 
weighting by Medicare Part B charges but excludes allied health costs 
for modeling and payment. Specifically, the proposed calculation 
removes allied health costs from cost center CCR calculations for 
specified ancillary cost centers, as discussed above, multiplies them 
by the Medicare Part B charges on Worksheet D, Part V, and sums these 
estimated Medicare costs. This sum is then divided by the sum of the 
same Medicare Part B charges for the same specified set of ancillary 
cost centers.
    As we indicated in the proposed rule (71 FR 49528), using the same 
cost report data in this study, we estimated a median overall CCR for 
the proposed calculation of 0.3081 (mean 0.3389) with a standard 
deviation of 0.1583. The similarity to the median and standard 
deviation of the ``traditional'' overall CCR calculation noted above 
(median 0.3040 and standard deviation of 0.1318) masks some sizeable 
changes in overall CCR calculations for specific hospitals due largely 
to the inclusion of Medicare Part B weighting.
    In order to isolate the overall impact of adopting this methodology 
on APC medians, we used the first 9 months of CY 2005 claims data to 
estimate APC median costs varying only the two methods of determining 
overall CCR. As stated in the CY 2007 OPPS proposed rule (71 FR 49528), 
we expected the impact to be limited because the majority of costs are 
estimated using a cost center-specific CCR and not the overall. As 
predicted, we observed minor changes in APC median costs from the 
adoption of the proposed overall CCR calculation. We largely observed 
differences of no more than 5 percent in either direction. The median 
overall percent change in APC cost estimates was -0.3 percent. We 
typically observe comparable changes in APC medians when we update our 
cost report data. Using updated cost report data for the calculations 
in this final rule with comment period, we estimate a median overall 
CCR across all hospitals of 0.3015 using the new overall CCR 
calculation.
    We believe that a single overall CCR calculation should be used for 
all components of the OPPS for both modeling and payment. Therefore, we 
proposed to use the modified overall CCR calculation as discussed above 
when the hospital-specific overall CCR is used for any of the following 
calculations: in the CMS calculation of median costs for OPPS 
ratesetting, in the CMS calculation of the outlier threshold, in the 
fiscal intermediary calculation of outlier payments, in the CMS 
calculation of statewide CCRs, in the fiscal intermediary calculation 
of pass-through payments for devices, and for any other fiscal 
intermediary payment calculation in which the current hospital-specific 
overall CCR may be used now or in the future.
    Comment: Several commenters supported the proposed change to the 
calculation of the overall CCR to be weighted by Part B charges and to 
exclude the costs of nursing and allied health professional education 
programs. One commenter asked that CMS provide examples at the line 
level of how the revenue code to cost center crosswalk is applied to 
sample claims to illustrate to hospitals how selection of the revenue 
code for any particular item or service controls the resulting cost 
that is used in median calculation. The commenter also asked that CMS 
instruct fiscal intermediaries to allow hospitals to reclassify expense 
and revenue whenever the hospital believes it is appropriate, to ensure 
that the charges on the claim result in appropriate costs for median 
setting and order the fiscal intermediaries not to reverse 
reclassification of costs in audit adjustments. The commenter also 
suggested that CMS should have fiscal intermediaries conduct a survey 
of their audit staff with regard to the validity of the revenue code to 
cost center crosswalk.
    Response: We continue to believe that the proposed change to the 
CCR calculation is appropriate, and we have used the revised formula to 
calculate the

[[Page 67985]]

overall CCRs used to set the medians on which the CY 2007 payment rates 
are based.
    With respect to the request for detailed examples to illustrate how 
selection of a revenue code will control the cost that is used in the 
median calculation, we believe that hospitals, like any business, are 
responsible for performing their own analysis regarding issues that 
affect their revenue stream. We have gone to great lengths in the 
preamble of our proposed and final rules to discuss how we derive costs 
from charges and how we crosswalk the charge from the revenue code 
reported for the charge to the cost center on the cost report. 
Moreover, the revenue code to cost center crosswalk has been on the CMS 
Web site for several years, open continuously to public comment. We do 
not believe it is necessary to create and publish examples at the 
claim-line level to further elaborate on how we convert charges to 
costs for purposes of establishing median costs. Hospitals that are 
interested should have sufficient information available already on this 
topic. Moreover, Medicare auditing rules have been well-established and 
standardized over many years, and we rely on our contractors to enforce 
them appropriately.
    Comment: One commenter suggested that CMS study the crosswalk that 
is used in the completion of the Provider Statistical and Reimbursement 
Report (PS&R) to determine whether changes to the CMS crosswalk of 
revenue codes to cost centers might be appropriate. Specifically, the 
commenter suggested the following revisions: Revenue code 0413 
(hyperbaric oxygen therapy) should be crosswalked to the hospital 
overall CCR; Revenue code 026X (IV therapy) could have cost center 5600 
(Drugs charges to patients) as the secondary default CCR before 
defaulting to the overall CCR; Revenue code 046X (Pulmondary therapy) 
should have cost center 4600 (respiratory therapy) as secondary and 
cost center 3160 as tertiary; and Revenue code 074X (EEG) should have 
cost center 5400 (EEG) as primary and cost center 3280 (EKG and EEG) as 
secondary.
    Response: We have not made any changes in response to the 
commenter's suggestions for CY 2007. However, we will carefully examine 
the commenter's suggestions with regard to the calculation of CCRs for 
the CY 2008 OPPS.
    After carefully considering all the public comments received, we 
are adopting our proposal for CY 2007 without modification. As stated 
in the CY 2007 proposed rule (71 FR 49529), we will issue a Medicare 
program instruction to fiscal intermediaries that will instruct them to 
recalculate and use the hospital-specific overall CCR as we have 
finalized for the above stated purposes.
2. Calculation of Median Costs for CY 2007
    In this section of the preamble, we discuss the use of claims to 
calculate the proposed OPPS payment rates for CY 2007. The hospital 
outpatient prospective payment page on the CMS Web site on which this 
final rule with comment period is posted provides an accounting of 
claims used in the development of the final rates: http://www.cms.hhs.gov/HospitalOutpatientPPS. The accounting of claims used in 
the development of this final rule with comment period is included on 
the Web site under supplemental materials for the CY 2007 final rule 
with comment period. That accounting provides additional detail 
regarding the number of claims derived at each stage of the process. In 
addition, below we discuss the files of claims that comprise the data 
sets that are available for purchase under a CMS data user contract. 
Our CMS Web site, http://www.cms.hhs.gov/HospitalOutpatientPPS, 
includes information about purchasing the following two OPPS data 
files: ``OPPS Limited Data Set'' and ``OPPS Identifiable Data Set.''
    As proposed, we used the following methodology to establish the 
relative weights to be used in calculating the OPPS payment rates for 
CY 2007 shown in Addenda A and B to this final rule with comment 
period. This methodology is as follows:
    We used outpatient claims for the full CY 2005, processed before 
June 30, 2006, to set the relative weights for CY 2007. To begin the 
calculation of the relative weights for CY 2007, we pulled all claims 
for outpatient services furnished in CY 2005 from the national claims 
history file. This is not the population of claims paid under the OPPS, 
but all outpatient claims (including, for example, CAH claims, and 
hospital claims for clinical laboratory services for persons who are 
neither inpatients nor outpatients of the hospital).
    We then excluded claims with condition codes 04, 20, 21, and 77. 
These are claims that providers submitted to Medicare knowing that no 
payment will be made. For example, providers submit claims with a 
condition code 21 to elicit an official denial notice from Medicare and 
document that a service is not covered. We then excluded claims for 
services furnished in Maryland, Guam, and the U.S. Virgin Islands, 
American Samoa, and the Northern Marianas because hospitals in those 
geographic areas are not paid under the OPPS.
    We divided the remaining claims into the three groups shown below. 
Groups 2 and 3 comprise the 110 million claims that contain hospital 
bill types paid under the OPPS.
    1. Claims that were not bill types 12X, 13X, 14X (hospital bill 
types), or 76X (CMHC bill types). Other bill types are not paid under 
the OPPS and, therefore, these claims were not used to set OPPS 
payment.
    2. Claims that were bill types 12X, 13X, or 14X (hospital bill 
types). These claims are hospital outpatient claims.
    3. Claims that were bill type 76X (CMHC). (These claims are later 
combined with any claims in item 2 above with a condition code 41 to 
set the per diem partial hospitalization rate determined through a 
separate process.)
    For the CCR calculation process, we used the same general approach 
as we used in developing the final APC rates for CY 2006 (70 FR 68537), 
with a change to the development of the overall CCR as discussed above. 
That is, we first limited the population of cost reports to only those 
for hospitals that filed outpatient claims in CY 2005 before 
determining whether the CCRs for such hospitals were valid.
    We then calculated the CCRs at a cost center level and overall for 
each hospital for which we had claims data. We did this using hospital-
specific data from the Healthcare Cost Report Information System 
(HCRIS). We used the most recent available cost report data, in most 
cases, cost reports for CY 2004. As proposed, for this final rule with 
comment period, we used the most recently submitted cost report to 
calculate the CCRs to be used to calculate median costs for the CY 2007 
OPPS. If the most recent available cost report was submitted but not 
settled, we looked at the last settled cost report to determine the 
ratio of submitted to settled cost using the overall CCR, and we then 
adjusted the most recent available submitted but not settled cost 
report using that ratio. We calculated both an overall CCR and cost 
center-specific CCRs for each hospital. We used the final overall CCR 
calculation discussed in II.A.1.c. of this preamble for all purposes 
that require use of an overall CCR.
    We then flagged CAH claims, which are not paid under the OPPS, and 
claims from hospitals with invalid CCRs. The latter included claims 
from hospitals without a CCR; those from hospitals paid an all-
inclusive rate; those from

[[Page 67986]]

hospitals with obviously erroneous CCRs (greater than 90 or less than 
.0001); and those from hospitals with CCRs that were identified as 
outliers (3 standard deviations from the geometric mean after removing 
error CCRs). In addition, we trimmed the CCRs at the cost center level 
by removing the CCRs for each cost center as outliers if they exceeded 
3 standard deviations from the geometric mean. This is the 
same methodology that we used in developing the final CY 2006 CCRs. For 
CY 2007, we proposed to trim at the departmental CCR level to eliminate 
aberrant CCRs that, if found in high volume hospitals, could skew the 
medians. We used a four-tiered hierarchy of cost center CCRs to match a 
cost center to every possible revenue code appearing in the outpatient 
claims, with the top tier being the most common cost center and the 
last tier being the default CCR. If a hospital's cost center CCR was 
deleted by trimming, we set the CCR for that cost center to 
``missing,'' so that another cost center CCR in the revenue center 
hierarchy could apply. If no other departmental CCR could apply to the 
revenue code on the claim, we used the hospital's overall CCR for the 
revenue code in question. For example, if a visit was reported under 
the clinic revenue code, but the hospital did not have a clinic cost 
center, we mapped the hospital-specific overall CCR to the clinic 
revenue code. The hierarchy of CCRs is available for inspection and 
comment at the CMS Web site: http://www.cms.hhs.gov/HospitalOutpatientPPS.
    We then converted the charges to costs on each claim by applying 
the CCR that we believed was best suited to the revenue code indicated 
on the line with the charge. Table 2 of the proposed rule (71 FR 49532) 
contained a list of the allowed revenue codes. Revenue codes not 
included in Table 2 are those not allowed under the OPPS because their 
services cannot be paid under the OPPS (for example, inpatient room and 
board charges) and thus, charges with those revenue codes were not 
packaged for creation of the OPPS median costs. One exception is the 
calculation of median blood costs, as discussed in section X. of this 
preamble.
    Thus, we applied CCRs as described above to claims with bill types 
12X, 13X, or 14X, excluding all claims from CAHs and hospitals in 
Maryland, Guam, and the U.S. Virgin Islands, American Samoa, and the 
Northern Marianas and claims from all hospitals for which CCRs were 
flagged as invalid.
    We identified claims with condition code 41 as partial 
hospitalization services of hospitals and moved them to another file. 
These claims were combined with the 76X claims identified previously to 
calculate the partial hospitalization per diem rate.
    We then excluded claims without a HCPCS code. We also moved claims 
for observation services to another file. We moved to another file 
claims that contained nothing but influenza and pneumococcal pneumonia 
(``PPV'') vaccine. Influenza and PPV vaccines are paid at reasonable 
cost and, therefore, these claims are not used to set OPPS rates. We 
note that the two above mentioned separate files containing partial 
hospitalization claims and observation services claims are included in 
the files that are available for purchase as discussed above.
    We next copied line-item costs for drugs, blood, and devices (the 
lines stay on the claim, but are copied off onto another file) to a 
separate file. No claims were deleted when we copied these lines onto 
another file. These line-items are used to calculate a per unit mean 
and median and a per day mean and median for drugs, radiopharmaceutical 
agents, blood and blood products, and devices, including but not 
limited to brachytherapy sources, as well as other information used to 
set payment rates, including a unit to day ratio for drugs.
    We then divided the remaining claims into the following five 
groups:
    1. Single Major Claims: Claims with a single separately payable 
procedure (that is, status indicator S, T, V, or X), all of which would 
be used in median setting.
    2. Multiple Major Claims: Claims with more than one separately 
payable procedure (that is, status indicator S, T, V, or X), or 
multiple units for one payable procedure. As discussed below, some of 
these can be used in median setting.
    3. Single Minor Claims: Claims with a single HCPCS code that is 
packaged (that is, status indicator N) and not separately payable.
    4. Multiple Minor Claims: Claims with multiple HCPCS codes that are 
packaged (that is, status indicator N) and not separately payable.
    5. Non-OPPS Claims: Claims that contain no services payable under 
the OPPS (that is, all status indicators other than S, T, V, X, or N). 
These claims are excluded from the files used for the OPPS. Non-OPPS 
claims have codes paid under other fee schedules, for example, durable 
medical equipment or clinical laboratory, and do not contain either a 
code for a separately paid service or a code for a packaged service.
    In previous years, we made a determination of whether each HCPCS 
code was a major code, or a minor code, or a code other than a major or 
minor code. We used those code-specific determinations to sort claims 
into these five identified groups. For the CY 2007 OPPS, we proposed to 
use status indicators, as described above, to sort the claims into 
these groups. We believed that using status indicators was an 
appropriate way to sort the claims into these groups and also to make 
our process more transparent to the public. We further believed that 
this proposed method of sorting claims would enhance the public's 
ability to derive useful information and become a more informed 
commenter on the proposed rule.
    We note that the claims listed in numbers 1, 2, 3, and 4 above are 
included in the data files that can be purchased as described above.
    We set aside the single minor, multiple minor claims and the non-
OPPS claims (numbers 3, 4, and 5 above) because we did not use these 
claims in calculating median costs. We then examined the multiple major 
claims for date of service to determine if we could break them into 
single procedure claims using the dates of service on all lines on the 
claim. If we could create claims with single major procedures by using 
date of service, we created a single procedure claim record for each 
separately paid procedure on a different date of service (that is, a 
``pseudo'' single).
    We then used the ``bypass codes'' listed in Table 1 of the proposed 
rule (71 FR 49517) and discussed in section II.A.1.b. of this preamble 
to remove separately payable procedures that we determined contain 
limited costs or no packaged costs, or were otherwise suitable for 
inclusion on the bypass list, from a multiple procedure bill. When one 
of the two separately payable procedures on a multiple procedure claim 
was on the bypass code list, we split the claim into two single 
procedure claims records. The single procedure claim record that 
contained the bypass code did not retain packaged services. The single 
procedure claim record that contained the other separately payable 
procedure (but no bypass code) retained the packaged revenue code 
charges and the packaged HCPCS charges.
    We also removed lines that contained multiple units of codes on the 
bypass list and treated them as ``pseudo'' single claims by dividing 
the cost for the multiple units by the number of units on the line. 
Where one unit of a single separately paid procedure code remained on 
the claim after removal of the multiple units of the bypass code, we 
created a ``pseudo'' single claim

[[Page 67987]]

from that residual claim record, which retained the costs of packaged 
revenue codes and packaged HCPCS codes. This enabled us to use claims 
that would otherwise be multiple procedure claims and could not be 
used. We excluded those claims that we were not able to convert to 
singles even after applying all of the techniques for creation of 
``pseudo'' singles.
    We then packaged the costs of packaged HCPCS codes (codes with 
status indicator ``N'' listed in Addendum B to this proposed rule) and 
packaged revenue codes into the cost of the single major procedure 
remaining on the claim. The list of packaged revenue codes was shown in 
Table 2 of the CY 2007 OPPS proposed rule (71 FR 49532) and below.
    After removing claims for hospitals with error CCRs, claims without 
HCPCS codes, claims for immunizations not covered under the OPPS, and 
claims for services not paid under the OPPS, 58.4 million claims were 
left. Of these 58.4 million claims, we were able to use some portion of 
54.1 million whole claims (92.6 percent of the 58.4 million potentially 
usable claims) to create the 98.5 million single and ``pseudo'' single 
claims for use in the CY 2007 median development and for ratesetting.
    We also excluded (1) claims that had zero costs after summing all 
costs on the claim and (2) claims containing packaging flag 3. 
Effective for services furnished on or after July 1, 2004, the 
Outpatient Code Editor (OCE) assigns packaging flag number 3 to claims 
on which hospitals submitted token charges for a service with status 
indicator ``S'' or ``T'' (a major separately paid service under OPPS) 
for which the fiscal intermediary is required to allocate the sum of 
charges for services with a status indicator equaling ``S'' or ``T'' 
based on the weight for the APC to which each code is assigned. We do 
not believe that these charges, which were token charges as submitted 
by the hospital, are valid reflections of hospital resources. 
Therefore, we deleted these claims. In the proposed rule, we deleted 
claims with payment flag 3 (not packaging flag 3) because we believed 
that payment flag 3 identified claims for which the charges were not as 
submitted by the provider as described above. As we were processing 
claims for this final rule with comment period, we realized that this 
was not the case and corrected the process to eliminate claims which, 
as described above, have charges that are not as submitted by the 
provider. See the CY 2007 final rule claims accounting under supporting 
documentation posted on our Web site, http://www.cms.hhs.gov/HospitalOutpatientPPS, for this final rule with comment period for 
further explanation. We note that in this final rule with comment 
period, as stated in both the proposed rule and here, we have excluded 
those claims that we believed were not valid reflections of hospital 
resources.
    We also deleted claims for which the charges equal the revenue 
center payment (that is, the Medicare payment) on the assumption that 
where the charge equals the payment, to apply a CCR to the charge would 
not yield a valid estimate of relative provider cost.
    For the remaining claims, we then standardized 60 percent of the 
costs of the claim (which we have previously determined to be the 
labor-related portion) for geographic differences in labor input costs. 
We made this adjustment by determining the wage index that applied to 
the hospital that furnished the service and dividing the cost for the 
separately paid HCPCS code furnished by the hospital by that wage 
index. As has been our policy since the inception of the OPPS, we 
proposed to use the pre-reclassified wage indices for standardization 
because we believed that they better reflect the true costs of items 
and services in the area in which the hospital is located than the 
post-reclassification wage indices, and would result in the most 
accurate adjusted median costs.
    We also excluded claims that were outside 3 standard deviations 
from the geometric mean of units for each HCPCS code on the bypass list 
(because, as discussed above, we used claims that contain multiple 
units of the bypass codes). We then deleted 438,440 single bills 
reported with modifier 50 that were assigned to APCs that contained 
HCPCS codes that are considered to be conditional or independent 
bilateral procedures under the OPPS and that are subject to special 
payment provisions implemented through the OCE. Modifier 50 signifies 
that the procedure was performed bilaterally. Although these are 
apparently single claims for a separately payable service and although 
there is only one unit of the code reported on the claim, the presence 
of modifier 50 signifies that two services were furnished. Therefore, 
costs reported on these claims are for two procedures and not for a 
single procedure. Hence, we deleted these multiple procedure records, 
which we would have treated as single procedure claims in prior OPPS 
updates.
    We used the remaining claims to calculate median costs for each 
separately payable HCPCS code and each APC. The comparison of HCPCS and 
APC medians determines the applicability of the ``2 times'' rule. As 
stated previously, section 1833(t)(2) of the Act provides that, subject 
to certain exceptions, the items and services within an APC group 
cannot be considered comparable with respect to the use of resources if 
the highest median (or mean cost, if elected by the Secretary) for an 
item or service in the group is more than 2 times greater than the 
lowest median cost for an item or service within the same group (``the 
2 times rule''). Finally, we reviewed the medians and reassigned HCPCS 
codes to different APCs as deemed appropriate. Section III.B. of this 
preamble includes a discussion of the HCPCS code assignment changes 
that resulted from examination of the medians and for other reasons. 
The APC medians were recalculated after we reassigned the affected 
HCPCS codes. Both the HCPCS medians and the APC medians were weighted 
to account for the inclusion of multiple units of the bypass codes in 
the creation of pseudo single bills.
    A detailed discussion of the medians for blood and blood products 
is included in section X. of this preamble. A discussion of the medians 
for APCs that require one or more devices when the service is performed 
is included in section IV.A. of this preamble. A discussion of the 
median for observation services is included in section XI. of this 
preamble, and a discussion of the median for partial hospitalization is 
included below in section II.B. of this preamble.
    We specifically invited public comment on the relative benefits of 
deleting claims reported with modifier 50 signifying two procedures 
were performed versus dividing the costs for the two procedures by two 
to create two ``pseudo'' single claims. We received one comment on this 
issue.
    Comment: One commenter supported deletion of the conditional or 
independent bilateral service claims because the commenter believes 
that the total cost of a bilateral procedure (including packaged costs) 
is generally less than 2 times the total cost of a unilateral 
procedure, and such cost savings are already reflected in each 
hospital's CCR. The commenter stated that to divide the cost of the 
bilateral procedure by two would result in ``pseudo'' singles that 
would underrepresent the full cost of a single procedure.
    Response: We have excluded claims for conditional and independent 
bilateral procedures from the claims we used to calculate the median 
costs for the CY 2007 OPPS. We will carefully consider how to treat 
these claims for future years.

[[Page 67988]]

    For the final CY 2007 OPPS ratesetting process, we deleted these 
claims, as we did for the proposed rule.
    We received many comments on our proposed CY OPPS data process. A 
summary of the comments and our responses follows:
    Comment: The commenters objected to what they view as wide 
fluctuations in the APC payment rates from CY 2006 to CY 2007, because 
such variability makes it difficult to plan and budget for the services 
that the hospital will provide in the upcoming year. The commenters 
objected to changes in proposed OPPS rates that are greater than 5 
percent from the prior year's rates and urged CMS to adjust rates so 
that no payment rate in CY 2007 declined by more than 5 percent 
compared to its payment in CY 2006. The commenters stated that more 
than 250 APC rates declined compared to their CY 2006 rates, some by 10 
to 20 percent or more. In contrast, they noted that over 300 APC rates 
increased, many substantially and by up to 30 percent compared to their 
CY 2006 rates. The commenters stated that they did not believe that the 
changes in the median costs were reflective of changes in hospital 
costs, because hospital costs do not vary so widely from year to year. 
The commenters indicated that they expected that after more than 5 
years of experience, the rates would no longer show such significant 
volatility and urged CMS to use more multiple claims data to set the 
median costs.
    Response: There are a number of factors pertinent to the OPPS that 
cause median costs to change from one year to the next. These include 
reassignment of HCPCS codes to APCs to rectify 2 times violations and 
to respond to public comments; the need to split costs derived from 
claims data among the many different HCPCS codes, which results in very 
few usable claims for some services; and annual changes in reported 
hospital charges and costs that provide the source of the cost data on 
which the system is based.
    Although the APC number and title may remain the same from year to 
year, we routinely reassign HCPCS codes to different APCs to resolve 
violations of the 2 times rule as required by law or reconfigure APCs 
to create more levels in a series. We also reassign codes in response 
to public comments when we believe that the requested reassignment will 
result in improved clinical homogeneity and more similar resource use 
for a particular service or group of services. To the extent that there 
has been a reassignment either into or out of an APC or a 
reconfiguration of an APC into multiple levels, a comparison of the APC 
median from 1 year to the next is often not a valid comparison of the 
costs for the same services. In addition, every year new HCPCS codes 
that were initially assigned to clinical APCs for payment purposes may 
begin to contribute claims data to those APC median costs, also leading 
to ill-founded comparisons across years.
    Moreover, many of the claims we receive for OPPS services are 
multiple procedure claims that must be fragmented for use in 
establishing the median costs for single procedures. Unlike other 
prospective payment systems in which the costs of multiple services are 
aggregated into a single payment for a defined encounter (for example, 
inpatient stay and home health episode of care), under the OPPS the 
costs that reflect the charges on Medicare claims that contain more 
than a single service on the same date must be fragmented into pieces 
to provide costs at a unit level, rather than being aggregated to 
provide the total cost for a set of services furnished in a single 
encounter. The more the costs on claims are split to accommodate 
payment for individual items and services described by HCPCS codes, and 
the fewer single bills that are available for ratesetting because the 
costs cannot be fragmented into unique services, the more variability 
is introduced into the cost. Because of the difficulty in assigning the 
revenue code charge data that hospitals submit on multiple procedure 
claims to the separately payable HCPCS codes that form the basis of 
payment in the OPPS, we must often use small numbers of claims to set 
the median costs for some services. We believe that the small numbers 
of single claims are the source of much of the volatility in the 
payment system. When we examine claims data for APCs like the Visit 
APCs, for which we have large and stable numbers of services, we do not 
see the median cost fluctuations that typically occur in those APCs for 
which we regularly have small numbers of single bills.
    However, we are rarely asked for larger APCs that contain more 
codes or for more packaging of payment for HCPCS codes into the APC 
rates, both of which would enable us to use more claims and, we 
believe, provide more stable payment rates. Indeed, payment in the OPPS 
has become more specific each year, largely in response to our 
willingness to accommodate the requests of stakeholders when we believe 
they are justified and supported by the data. Each year, we are asked 
for increasingly more APCs that contain fewer HCPCS codes, as well as 
more precise costing of particular services. Generally, the comments 
received in response to our proposed rule asked for more separate 
payment, less packaging, and greater service-specific precision in the 
calculation of median costs for specifically identified services in the 
OPPS. We are also often asked to specifically recalculate median costs 
by using subsets of claims that meet specific criteria or by applying 
alternative methodologies for identified services. While these special 
approaches are generally intended to increase payments for their 
particular services of interest, they likely contribute to less 
stability in the system in general. Inevitably, such specificity would 
lead to more, not less, volatility as it would reduce the number of 
claims that can be used to set median costs.
    Lastly, hospital charges and costs are the foundation of the 
payment weights, but hospitals change the mix of services they furnish 
and thereby also change their cost structure to some extent each year. 
Moreover, hospitals increase, sometimes decrease, or hold steady their 
charges each year based on a variety of business reasons, but these 
changes to charges often vary across the different services they 
furnish. Thus, hospital decisions to change their mix of services or to 
change their charges for some services differentially also contribute 
to the volatility in payment rates.
    We recognize that it could be desirable for a payment system's 
rates to not vary by a certain percentage from the prior year's payment 
rates, but there is no reason to believe that limiting the changes in 
payment rates to prevent a decline by any percentage each year would be 
accurately reflective of changes in relative costs. Although the 
commenters asked that no payment for any service decline by more than 5 
percent, none addressed a limitation for a payment increase. We do not 
believe that it is appropriate to artificially impose limits on a 
payment rate's increase or decrease from one year to the next, because, 
as noted above, comparisons between APC payment rates from year to year 
have little meaning for the many APCs that have experienced HCPCS 
migration. Moreover, to limit the increases or decreases in payment to 
a set amount for all services would conflict with the statutory 
requirement that at least annually we revise APCs and other components 
of the OPPS using new cost data and other relevant information. 
Therefore, we are not adjusting the rates as requested to account for a 
decline of more than 5 percent from CY 2006 in the final CY 2007 OPPS 
payment rates. We will continue to explore ways to use the data from 
multiple procedure claims because we agree that a high level of

[[Page 67989]]

volatility is not desirable in the OPPS, and we also believe that the 
most viable long term solution to instability is the use of all the 
claims data. However, we also believe that changes in median costs from 
one year to the next are unavoidable in a relative weight payment 
system which also depends on hospital charges and costs and in which 
reassignment of HCPCS codes from one APC to another is required by law 
in cases of 2 times violations. As the commenters noted, some CY 2007 
APC payment rates decrease but others increase in comparison with the 
CY 2006 rates, consistent with expectations for a budget neutral 
payment system like the OPPS.
    Comment: One commenter objected to the inclusion of charges from 
the following revenue codes as packaged services under the OPPS: (1) 
Revenue code 274 (Prosthetic/orthotic devices) on the basis that the 
revenue code is for nonimplanted devices that require a HCPCS code, are 
paid under the MPFS, and have a status indicator of ``A'' under the 
OPPS; (2) Revenue code 280 (Oncology) on the basis that there is no 
oncology service that would not be coded by a HCPCS code, and, 
therefore, any charge without a HCPCS code should not be packaged; (3) 
Revenue code 290 (Durable Medical Equipment (DME)) on the basis that 
DME is for use in the home and not in the outpatient setting; (4) 
Revenue codes 343 and 344 (Diagnostic radiopharmaceuticals and 
therapeutic radiopharmaceuticals) on the basis that they are required 
to be billed with a HCPCS code, and, therefore, charges without a HCPCS 
code should not be packaged; and (5) Revenue code 560 (Medical Social 
Services) on the basis that they are separately billable only by home 
health agencies and are, therefore, suspect and should not be packaged.
    Response: With a few limited exceptions, CMS does not specify the 
revenue codes hospitals must use to report their charges. Therefore, we 
selected a generous set of revenue codes to maximize the likelihood 
that we would capture all of the costs of a particular service for 
purposes of calculating the median costs on which the OPPS payment 
rates are based. To cease packaging costs under these revenue codes 
where there is no HCPCS code reported on the line may result in 
erroneous reductions in median costs and, therefore, in the related 
OPPS payment rates. With regard to the specific concerns of the 
commenter, our responses regarding the rationale for packaging the 
revenue code charges for each revenue code of interest follow: (1) 
Revenue code 274 is one of the revenue codes we previously instructed 
hospitals to use to report devices that had been paid as pass-through 
devices; (2) Revenue code 280 is packaged because we believe that it is 
possible that a hospital could have costs related to packaged OPPS 
services for which it would choose not to bill a HCPCS code, and we 
want to ensure that those costs are not lost in median calculation; (3) 
Revenue code 290 (DME) is governed by the statute which explicitly 
states that implantable DME provided in hospitals is paid under the 
OPPS, and we believe that it is possible that hospitals may charge for 
implantable DME but not bill a HCPCS code for the items; (4) Revenue 
codes 343 and 344 (diagnostic and therapeutic radiopharmaceuticals) are 
included as hospitals may charge for these items without placing a 
HCPCS code on the line; (5) Revenue code 560 (Medical Social Services) 
is included because hospitals may charge without billing a HCPCS code 
for the services of a medical social worker that are related to a visit 
service and thus would otherwise not be packaged into the median cost 
for the visit. We note that National Uniform Billing Committee 
guidelines on use of revenue code 560 recognize that it may be reported 
by hospitals in some circumstances.
    Comment: One commenter asked that CMS implement an indirect medical 
education adjustment under the CY 2007 OPPS to address what the 
commenter states is a 23-percent shortfall to the market basket for 
OPPS services. The commenter indicated that this adjustment was needed 
to reimburse hospitals for the higher costs incurred by major teaching 
hospitals to provide outpatient care to Medicare beneficiaries.
    Response: We do not believe an indirect medical education add-on 
payment is appropriate in a budget neutral payment system where such 
changes would result in reduced payments to all other hospitals. 
Moreover, in this final rule with comment period, we have developed 
payment weights that we believe resolve many of the public concerns 
regarding appropriate payments for new technology services and device-
dependent procedures that we believe are furnished largely by teaching 
hospitals. We believe this and other payment changes should help ensure 
adequate and appropriate payment for teaching hospitals.
    Comment: One commenter supported CMS' proposal to discard claims 
that contain token charges for packaged devices but opposed discarding 
claims when there is only one separately paid procedure on the claim, 
although there are other packaged services billed with token charges on 
other lines of the claim.
    Response: We have not discarded claims that contain token charges 
where there is only one separately paid procedure on the claim if there 
are other packaged services billed with token charges on other lines of 
the claim. We discarded claims with token charges only when such claims 
included token charges for devices with procedure codes that are 
assigned to device-dependent APCs, because we instructed hospitals to 
bill token charges for devices that were replaced without cost to the 
provider due for example, to warranty, field action or recall. We also 
discarded claims that, as submitted, contained token charges for 
separately paid (not packaged) procedure codes, which during claims 
processing were converted to imputed charges for purposes of applying 
the outlier policy and which came to us through the national claims 
history with the imputed charges. These claims are identified with a 
packaging flag 3 and are excluded because the charges shown on the 
claim we receive were not the charges submitted by the provider. We 
discuss this in more detail in the CY 2007 final rule claims accounting 
on the CMS OPPS Web page at http://www.cms.hhs.gov/HospitalOutpatientPPS/.
    After carefully considering all public comments received, we are 
finalizing the list of packaged services by revenue code shown in Table 
2 and our data process for calculating the median costs for OPPS 
services furnished on or after January 1, 2007, without modification. 
Table 2 below contains the list of packaged services by revenue code 
that we used in developing the APC relative weights listed in Addenda A 
and B of this final rule with comment period.

           Table 2.--CY 2007 Packaged Services by Revenue Code
------------------------------------------------------------------------
           Revenue code                          Description
------------------------------------------------------------------------
250...............................  PHARMACY.

[[Page 67990]]

 
251...............................  GENERIC.
252...............................  NONGENERIC.
254...............................  PHARMACY INCIDENT TO OTHER
                                     DIAGNOSTIC.
255...............................  PHARMACY INCIDENT TO RADIOLOGY.
257...............................  NONPRESCRIPTION DRUGS.
258...............................  IV SOLUTIONS.
259...............................  OTHER PHARMACY.
260...............................  IV THERAPY, GENERAL CLASS.
262...............................  IV THERAPY/PHARMACY SERVICES.
263...............................  SUPPLY/DELIVERY.
264...............................  IV THERAPY/SUPPLIES.
269...............................  OTHER IV THERAPY.
270...............................  M&S SUPPLIES.
271...............................  NONSTERILE SUPPLIES.
272...............................  STERILE SUPPLIES.
274...............................  PROSTHETIC/ORTHOTIC DEVICES.
275...............................  PACEMAKER DRUG.
276...............................  INTRAOCULAR LENS SOURCE DRUG.
278...............................  OTHER IMPLANTS.
279...............................  OTHER M&S SUPPLIES.
280...............................  ONCOLOGY.
289...............................  OTHER ONCOLOGY.
290...............................  DURABLE MEDICAL EQUIPMENT.
343...............................  DIAGNOSTIC RADIOPHARMS.
344...............................  THERAPEUTIC RADIOPHARMS.
370...............................  ANESTHESIA.
371...............................  ANESTHESIA INCIDENT TO RADIOLOGY.
372...............................  ANESTHESIA INCIDENT TO OTHER
                                     DIAGNOSTIC.
379...............................  OTHER ANESTHESIA.
390...............................  BLOOD STORAGE AND PROCESSING.
399...............................  OTHER BLOOD STORAGE AND PROCESSING.
560...............................  MEDICAL SOCIAL SERVICES.
569...............................  OTHER MEDICAL SOCIAL SERVICES.
621...............................  SUPPLIES INCIDENT TO RADIOLOGY.
622...............................  SUPPLIES INCIDENT TO OTHER
                                     DIAGNOSTIC.
624...............................  INVESTIGATIONAL DEVICE (IDE).
630...............................  DRUGS REQUIRING SPECIFIC
                                     IDENTIFICATION, GENERAL CLASS.
631...............................  SINGLE SOURCE.
632...............................  MULTIPLE.
633...............................  RESTRICTIVE PRESCRIPTION.
681...............................  TRAUMA RESPONSE, LEVEL I.
682...............................  TRAUMA RESPONSE, LEVEL II.
683...............................  TRAUMA RESPONSE, LEVEL III.
684...............................  TRAUMA RESPONSE, LEVEL IV.
689...............................  TRAUMA RESPONSE, OTHER.
700...............................  CAST ROOM.
709...............................  OTHER CAST ROOM.
710...............................  RECOVERY ROOM.
719...............................  OTHER RECOVERY ROOM.
720...............................  LABOR ROOM.
721...............................  LABOR.
762...............................  OBSERVATION ROOM.
810...............................  ORGAN ACQUISITION.
819...............................  OTHER ORGAN ACQUISITION.
942...............................  EDUCATION/TRAINING.
------------------------------------------------------------------------

3. Calculation of Scaled OPPS Payment Weights
    Using the median APC costs discussed previously, we calculated the 
final relative payment weights for each APC for CY 2007 shown in 
Addenda A and B of this final rule with comment period. In prior years, 
we scaled all the relative payment weights to APC 0601 (Mid Level 
Clinic Visit) because it is one of the most frequently performed 
services in the hospital outpatient setting. We assigned APC 0601 a 
relative payment weight of 1.00 and divided the median cost for each 
APC by the median cost for APC 0601 to derive the relative payment 
weight for each APC.
    As proposed, for the CY 2007 OPPS, we scaled all of the relative 
payment weights to APC 0606 (Level 3 Clinic Visits) because we deleted 
APC 0601, as part of the reconfiguration of the visit APCs. We chose 
APC 0606 as the scaling base because under our proposal to reconfigure 
the APCs where clinic visits are assigned for CY 2007, APC 0606 is the 
middle level clinic visit APC (that is, Level 3 of five levels). We 
have historically used the median cost of the middle level clinic visit 
APC (that is APC 0601 through CY 2006) to calculate unscaled weights 
because mid-level clinic visits are among the most frequently performed 
services in the hospital outpatient setting. Therefore, to maintain 
consistency in using a median

[[Page 67991]]

for calculating unscaled weights representing the median cost of some 
of the most frequently provided services, we proposed to continue to 
use the median cost of the middle level clinic APC, proposed APC 0606, 
to calculate unscaled weights. Following our standard methodology, but 
using the CY 2007 median for APC 0606, we assigned APC 0606 a relative 
payment weight of 1.00 and divided the median cost of each APC by the 
median cost for APC 0606 to derive the unscaled relative payment weight 
for each APC. The choice of the APC on which to base the relative 
weights for all other APCs does not affect the payments made under the 
OPPS because we scale the weights for budget neutrality.
    Section 1833(t)(9)(B) of the Act requires that APC reclassification 
and recalibration changes, wage index changes, and other adjustments be 
made in a manner that assures that aggregate payments under the OPPS 
for CY 2007 are neither greater than nor less than the aggregate 
payments that would have been made without the changes. To comply with 
this requirement concerning the APC changes, we compared aggregate 
payments using the CY 2006 relative weights to aggregate payments using 
the CY 2007 final relative payment weights. Based on this comparison, 
we adjusted the relative weights for purposes of budget neutrality. The 
unscaled relative payment weights were adjusted by 1.364598352 for 
budget neutrality. We recognize the scaler, or weight scaling factor, 
for budget neutrality that we proposed for CY 2007 is higher than any 
previous OPPS weight scaler as a result of our proposal to use APC 0606 
as the base for calculation of relative weights. Our use of the median 
cost for APC 0606 of $83.39 based on final rule with comment period 
data causes the unscaled weights to be lower than they would have been 
if we had chosen APC 0605 (Level 2 Clinic Visits; median $60.13 as the 
scaling base. The CY 2007 median cost of APC 0606 is significantly 
higher than the CY 2006 median cost of APC 0601 for mid-level clinic 
visits, which was used in CY 2006 and earlier years to calculate 
unscaled weights. Historically, the median cost for APC 0601 has been 
similar to the CY 2007 proposed median cost for APC 0605. In order to 
appropriately scale the total weight estimated for OPPS in CY 2007 to 
be similar to the total weight in OPPS for CY 2006, we calculated a 
scaler of 1.364598352 for this final rule with comment period, which is 
higher using APC 0606 as the base than it would be if we used APC 0605 
as the base. In addition to adjusting for increases and decreases in 
weight due the recalibration of APC medians, the scaler also accounts 
for any change in the base.
    The final relative payment weights listed in Addenda A and B of 
this final rule with comment period incorporate the recalibration 
adjustments discussed in sections II.A.1. and 2. of this preamble.
    Section 1833(t)(14)(H) of the Act, as added by section 621(a)(1) of 
Pub. L. 108-173, states that ``Additional expenditures resulting from 
this paragraph shall not be taken into account in establishing the 
conversion factor, weighting and other adjustment factors for 2004 and 
2005 under paragraph (9) but shall be taken into account for subsequent 
years.'' Section 1833(t)(14) of the Act provides the payment rates for 
certain ``specified covered outpatient drugs.'' Therefore, the cost of 
those specified covered outpatient drugs (as discussed in section V. of 
this preamble) is now included in the budget neutrality calculations 
for CY 2007 OPPS.
    Under section 1833(t)(16)(C) of the Act, as added by section 
621(b)(1) of Pub. L. 108-173, payment for devices of brachytherapy 
consisting of a seed or seeds (or radioactive source) is to be made at 
charges adjusted to cost for services furnished on or after January 1, 
2004, and before January 1, 2007. As we stated in our January 6, 2004 
interim final rule, charges for the brachytherapy sources were not used 
in determining outlier payments, and payments for these items were 
excluded from budget neutrality calculations for the CY 2006 OPPS. We 
excluded these payments from budget neutrality calculations, in part, 
because of the challenge posed by estimating hospital-specific cost 
payment. As proposed, for CY 2007, we calculated specific payment rates 
for brachytherapy sources, which were subjected to scaling for budget 
neutrality. (We provide a discussion of brachytherapy payment issues, 
including their CY 2007 treatment with respect to outlier payments, 
under section VII. of this preamble.) Therefore, the costs of 
brachytherapy sources are accounted for in the scaler of 1.364598352.
4. Changes to Packaged Services
    Payments for packaged services under the OPPS are bundled into the 
payments providers receive for separately payable services provided on 
the same day. Packaged services are identified by the status indicator 
``N.'' Hospitals include charges for packaged services on their claims, 
and the costs associated with these packaged services are then bundled 
into the costs for separately payable procedures on those same claims 
in establishing payment rates for the separately payable services. This 
is consistent with the principles of a prospective payment system based 
upon groupings of services and in contrast to a fee schedule that 
provides individual payment for each service billed. Hospitals may use 
CPT codes to report any packaged services that were performed, 
consistent with CPT coding guidelines.
    As a result of requests from the public, a Packaging Subcommittee 
to the APC Panel was established to review all the procedural CPT codes 
with a status indicator of ``N.'' Providers have often suggested that 
many packaged services could be provided alone, without any other 
separately payable services on the claim, and requested that these 
codes not be assigned status indicator ``N.'' In deciding whether to 
package a service or pay for a code separately, we consider a variety 
of factors, including whether the service is normally provided 
separately or in conjunction with other services; how likely it is for 
the costs of the packaged code to be appropriately mapped to the 
separately payable codes with which it was performed; and whether the 
expected cost of the service is relatively low.
    The Packaging Subcommittee identified areas for change for some 
packaged CPT codes that it believed could frequently be provided to 
patients as the sole service on a given date and that required 
significant hospital resources as determined from hospital claims data.
    Based on the comments received, additional issues, and new data 
that we shared with the Packaging Subcommittee concerning the packaging 
status of codes for CY 2007, the Packaging Subcommittee reviewed the 
packaging status of numerous HCPCS codes and reported its findings to 
the APC Panel at its March 2006 meeting. The APC Panel accepted the 
report of the Packaging Subcommittee, heard several presentations on 
certain packaged services, discussed the deliberations of the Packaging 
Subcommittee, and recommended that--
     CMS pay separately for HCPCS code 0069T (Acoustic heart 
sound recording and computer analysis; acoustic heart sound and 
computer analysis only).
     CMS maintain the packaged status of HCPCS code 0152T 
(Computer aided detection with further physician review for 
interpretation, with or without digitization of films radiographic 
images; chest radiograph(s)).

[[Page 67992]]

     CMS maintain the packaged status of CPT code 36500 (Venous 
catheterization for selective blood organ sampling).
     CMS pay separately for CPT code 36540 (Collection of blood 
specimen from a completely implantable venous access device) if there 
are no separately payable OPPS services on the claim.
     CMS pay separately for CPT code 36600 (Arterial puncture; 
withdrawal of blood for diagnosis) if there are no separately payable 
OPPS services on the claim.
     CMS pay separately for CPT code 38792 (Injection procedure 
for identification of sentinel node) if there are no separately payable 
OPPS services on the claim.
     CMS maintain the packaged status of CPT codes 74328 
(Endoscopic catheterization of the biliary ductal system, radiological 
supervision and interpretation), 74329 (Endoscopic catheterization of 
the pancreatic ductal system, radiological supervision and 
interpretation), and 74330 (Combined endoscopic catheterization of the 
biliary and pancreatic ductal systems, radiological supervision and 
interpretation).
     CMS pay separately for CPT code 75893 (Venous sampling 
through catheter, with or without angiography (eg, for parathyroid 
hormone, rennin), radiological supervision and interpretation) if there 
are no separately payable OPPS services on the claim.
     CMS continue to separately pay for CPT code 76000 
(Fluoroscopy (separate procedures), up to one hour physician time, 
other than 71023 or 71024 (eg, cardiac fluoroscopy)).
     CMS maintain the packaged status of CPT codes 76001 
(Fluoroscopy, physician time more than one hour, assisting a non-
radiologic physician (eg, nephrostolithotomy, ERCP, bronchoscopy, 
transbronchial biopsy)), 76003 (Fluoroscopic guidance for needle 
placement (eg, biopsy, aspiration, injection, localization device)), 
and 76005 (Fluoroscopic guidance and localization of needle or catheter 
tip for spine or paraspinous diagnostic or therapeutic injection 
procedures (epidural, transforaminal epidural, subarachnoid, 
paravertebral fact joint, paravertebral facet joint nerve or sacroiliac 
joint), including neurolytic agent destruction).
     CMS maintain the packaged status of CPT codes 76937 
(Ultrasound guidance for vascular access requiring ultrasound 
evaluation of potential access sites, documentation of selected vessel 
patency, concurrent realtime ultrasound visualization of vascular 
needle entry, with permanent recording and reporting) and 75998 
(Fluoroscopic guidance for central venous access device placement, 
replacement (catheter only or complete), or removal (includes 
fluoroscopic guidance for vascular access and catheter manipulation, 
any necessary contrast injections through access site or catheter with 
related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position)).
     CMS provide separate payment for CPT codes 94760 
(Noninvasive ear or pulse oximetry for oxygen saturation; single 
determination), 94761 (Noninvasive ear or pulse oximetry for oxygen 
saturation; multiple determinations), and 94762 (Noninvasive ear or 
pulse oximetry for oxygen saturation by continuous overnight 
monitoring) if there are no separately payable OPPS services on the 
claim.
     CMS pay separately for CPT code 96523 (Irrigation of 
implanted venous access device for drug delivery systems) if there are 
no separately payable OPPS services on the claim.
     CMS maintain the packaged status of HCPCS code G0269 
(Placement of occlusive device into either a venous or arterial access 
site).
     CMS pay separately for HCPCS code P9612 (Catheterization 
for collection of specimen, single patient) if there are no separately 
payable OPPS services on the claim.
     CMS bring data to the next APC Panel meeting that show the 
following: (a) how the costs of packaged items and services are 
incorporated into the median costs of APCs and (b) how the costs of 
these packaged items and services influence payments for associated 
procedures.
     The Packaging Subcommittee continue until the next APC 
Panel meeting.
    At its August 2006 meeting, the Packaging Subcommittee further 
discussed the packaging status of several of the HCPCS codes described 
above and reported its findings to the APC Panel. The APC Panel 
accepted the report of the Packaging Subcommittee, heard one 
presentation, reviewed one written comment, and discussed the 
deliberations of the Packaging Subcommittee. The APC Panel made the 
following recommendations for CY 2007:
    + That CMS package new CPT codes 0174T, Computer aided detection 
(CAD) (computer algorithm analysis of digital image data for lesion 
detection) with further physician review for interpretation and report, 
with or without digitization of film radiographic images, chest 
radiograph(s), performed concurrent with primary interpretation (List 
separately in addition to code for primary procedure), and 0175T, 
Computer aided detection (CAD ) (computer algorithm analysis of digital 
image data for lesion detection) with further physician review for 
interpretation and report, with or without digitization of film 
radiographic images, chest radiograph(s), performed remote from primary 
interpretation).
    + That CMS continue to package revised CPT code 0069T (Acoustic 
heart sound recording and computer analysis; acoustic heart sound 
recording and computer analysis only).
    + That CMS assign CPT code 96523 (Irrigation of implanted venous 
access device for drug delivery systems) status indicator ``Q'' as a 
``special'' packaged code.
    For CY 2007, we proposed to maintain CPT code 0069T as a packaged 
service and not adopt the APC Panel's March 2006 recommendation to pay 
separately for this code. The service uses signal processing technology 
to detect, interpret, and document acoustical activities of the heart 
through special sensors applied to a patient's chest. This code was a 
new Category III CPT code implemented in the CY 2005 OPPS and assigned 
a new interim status indicator of ``N'' in the CY 2005 OPPS final rule 
with comment period. The APC Panel recommended packaging CPT code 0069T 
for CY 2006, and we accepted that recommendation when we finalized the 
status indicator ``N'' assignment to 0069T for CY 2006. CPT code 0069T 
is an add-on code to an electrocardiography (ECG) service for CYs 2005 
and 2006. However on July 1, 2006, the AMA released to the public a 
code descriptor change to remove the add-on code designation for CPT 
code 0069T. The effective date of this change is January 1, 2007, at 
which point the descriptor will be ``Acoustic heart sound recording and 
computer analysis; acoustic heart sound recording and computer analysis 
only.'' We do not include Category III CPT codes that are released in 
July of a given year in the OPPS proposed rule for the following 
calendar year because of timing restraints. We include these codes in 
the OPPS final rule where they are assigned interim comment indicator 
``NI'' to denote that they are open for public comment.
    In its March 2006 presentation to the APC Panel, a manufacturer 
requested that we pay separately for CPT code 0069T and assign it to 
APC 0099 (Electrocardiograms), based on its estimated cost and clinical 
characteristics. The manufacturer stated

[[Page 67993]]

that the acoustic heart sound recording and analysis service may be 
provided with or without a separately reportable electrocardiogram. 
Members of the APC Panel engaged in extensive discussion of clinical 
scenarios as they considered whether CPT code 0069T could or could not 
be appropriately reported alone or in conjunction with several 
different procedure codes.
    During the August 2006 meeting, the Packaging Subcommittee further 
discussed CMS's proposal to package CPT 0069T for CY 2007 and the CY 
2007 code descriptor change, and ultimately recommended to the APC 
Panel that CMS continue to package this code for CY 2007. The APC Panel 
accepted this recommendation.
    Comment: One commenter requested that CMS pay separately for CPT 
code 0069T for CY 2007, mapping the code to an APC paying between $63 
and $97. The commenter clarified that this service is sometimes 
provided with an ECG and sometimes provided without an ECG, according 
to its revised descriptor for CY 2007. The commenter could not explain 
the low median cost that was calculated from the claims data, but 
suggested that the nine claims used to calculate the median were 
miscoded. The commenter estimated the cost of the service to be 
approximately $80 per procedure, significantly higher than the median 
cost for APC 0099 (Electrocardiograms), which was $23.60 based on the 
CY 2005 data that were used to calculate the CY 2007 proposed median 
costs. Though the commenter agreed that it would be rare for the 
acoustic heart sound procedure to be performed alone without any other 
OPPS services, the commenter disagreed that the procedure would be 
``associated'' with other services. Instead, the commenter clarified 
that it could be provided with a broad range of services, such as an 
emergency department visit, clinic visit, chest x-ray, or ECG. In 
addition, the commenter did not expect this service to have a 
meaningful impact on the median costs of those services because 
acoustic heart services are expected to be provided infrequently, 
compared to the total number of emergency department and clinic visits, 
chest x-rays, and ECGs.
    Response: Despite the change in add-on status for CPT code 0069T 
for CY 2007, based on the clinical uses that were described during the 
March 2006 APC Panel meeting and in the public comments, we believe 
that it is highly unlikely that CPT code 0069T would be performed in 
the hospital outpatient department as a sole service without other 
separately payable OPPS services. Payment for CPT code 0069T could 
always be packaged into payments for those other services. Therefore, 
we believe that CPT code 0069T is appropriately packaged because it 
would usually be closely linked to the performance of an ECG, and would 
rarely, if ever, be the only OPPS service provided to a patient. We 
understand that the commenter is clarifying that this service is not 
required to be provided in conjunction with an ECG. However, we 
continue to believe that it is likely that an ECG or other separately 
payable service would be performed on the patient in conjunction with 
the acoustic heart sound service. Therefore, we believe that it is 
appropriate to continue packaging CPT code 0069T for CY 2007. In 
addition, this service is estimated to require only minimal hospital 
resources. Using CY 2005 claims that have been updated with more recent 
CCRs, we had only nine single claims for CPT code 0069T, with a median 
line-item cost of $2.45, consistent with its low expected cost. 
Packaging payment for CPT code 0069T is consistent with the principles 
of a prospective payment system that provides payments for groups of 
services. To the extent that the acoustic heart sounding recording 
service may be more frequently provided in the future in association 
with ECGs or other OPPS services as its clinical indications evolve, we 
expect that its cost would also be increasingly reflected in the median 
costs for those other services, particularly ECG procedures.
    After carefully considering all comments received, we are adopting 
the APC Panel's August 2006 recommendation to continue to package this 
code for CY 2007. Therefore we are finalizing our proposal without 
modification to maintain CPT code 0069T as a packaged service for CY 
2007.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
to maintain the packaged status of CPT code 0152T. The service involves 
the application of computer algorithms and classification technologies 
to chest x-ray images to acquire and display information regarding 
chest x-ray regions that may contain indications of cancer. This code 
was a new Category III CPT code implemented in the CY 2006 OPPS and 
assigned a new interim status indicator of ``NI'' in the CY 2006 OPPS 
final rule with comment period. For CY 2006, the code is indicated as 
an add-on code to chest x-ray CPT codes, according to the AMA's CY 2006 
CPT book. However, on July 1, 2006, the AMA released to the public an 
update that deletes code 0152T for CY 2007 and replaces it with two new 
Category III CPT codes, 0174T and 0175T. Effective January 1, 2007, the 
descriptor for CPT code 0174T will be ``Computer aided detection (CAD) 
(computer algorithm analysis of digital image data for lesion 
detection) with further physician review for interpretation and report, 
with or without digitization of film radiographic images, chest 
radiograph(s), performed concurrent with primary interpretation (List 
separately in addition to code for primary procedure) and the 
descriptor for 0175T will be ``Computer aided detection (CAD) (computer 
algorithm analysis of digital image data for lesion detection) with 
further physician review for interpretation and report, with or without 
digitization of film radiographic images, chest radiograph(s), 
performed remote from primary interpretation.''
    As indicated above, we do not include Category III CPT codes that 
are released in July of a given year in the OPPS proposed rule for the 
following calendar year because of timing restraints. We include these 
codes in the OPPS final rule, where they are assigned new interim 
comment indicator ``NI'' to denote that they are open to comment.
    In its March 2006 presentation to the APC Panel, before the AMA had 
released the CY 2007 changes to this code, the manufacturer requested 
that we pay separately for this service and assign it to a New 
Technology APC with a payment rate of $15, based on its estimated cost, 
clinical considerations, and similarity to other image post-processing 
services that are paid separately. We proposed to accept the APC 
Panel's recommendation to package CPT code 0152T for CY 2007.
    In its August 2006 presentation to the APC Panel, after the AMA had 
released the CY 2007 code changes, the manufacturer requested that we 
assign both of these two new codes to a New Technology APC with a 
payment rate of $15. The APC Panel members discussed these codes 
extensively. They considered the possibility of treating CPT code 0175T 
as a ``special'' packaged code, thereby assigning payment to the code 
only when it was performed by a hospital without any other separately 
payable OPPS service also provided on the same day. They questioned the 
meaning of the word ``remote'' in the code descriptor for CPT code 
0175T, noting that is was unclear as to whether ``remote'' referred to 
time, geography, or a specific provider. They thought it was likely 
that a hospital without a CAD system that performed a chest x-ray and 
sent the x-ray to another hospital for performance of the CAD would be 
providing the CAD service under arrangement and, therefore, would be 
providing at least one other

[[Page 67994]]

service (chest x-ray) that would be separately paid. Thus, even in 
these cases, payment for the CAD service could be appropriately 
packaged. After significant deliberation, the Panel recommended that we 
package both of the new CPT codes, 0174T and 0175T, for CY 2007.
    Comment: One commenter requested that CMS pay separately for CPT 
codes 0174T and 0175T, mapping them to New Technology APC 1492, with a 
payment rate of $15. The commenter indicated that there is no basis for 
believing that chest x-ray computer-aided detection (CAD) will increase 
the number of chest x-rays performed in the outpatient setting, because 
chest x-ray CAD is not a screening tool and should only be applied to 
chest x-rays that are suspicious for lung cancer. The commenter also 
indicated that separate resources are required for chest x-ray CAD that 
are not required for a standard chest x-ray. In addition, the commenter 
stated that chest x-ray CAD can be performed at a different time or 
location or by a different provider than the chest x-ray. In these 
cases, the commenter believed that separate payment would be 
appropriate. The commenter was concerned that if hospitals are not paid 
separately for this technology, they will not be able to provide it, 
thereby limiting beneficiary access to chest x-ray CAD.
    Response: We agree with the APC Panel that packaged payment for 
chest x-ray CAD under a prospective payment methodology for outpatient 
hospital services is appropriate because of the close relationship of 
chest x-ray CAD to chest x-ray services and its projected modest cost. 
We do not believe that CPT code 0174T would ever be performed as a sole 
service without other separately payable OPPS services, based on the 
code definition as an add-on service performed concurrent with the 
primary interpretation of a chest x-ray. We believe that payment for 
CPT code 0174T is appropriately packaged into payment for the chest x-
ray services it accompanies. Payment for chest x-rays is provided 
through APC 0260 (Level I Plain Film Except Teeth), with a CY 2007 
median cost of $43.35. The median costs for the individual x-ray 
services that can be reported with the CAD technology range from $36.00 
to $56.11, easily overlapping the modest additional costs of providing 
chest x-ray CAD services. Although CPT code 0175T applies to chest x-
ray CAD that is ``remote'' from the primary interpretation, the 
definition of ``remote'' as used in the code descriptor is vague, with 
respect to time, geography, or a specific provider, so the 
circumstances in which it would be the only service provided by a 
hospital are also unclear. As discussed by the APC Panel if an x-ray 
were sent to another hospital for performance of the CAD, the CAD 
service would likely be provided under arrangement, in which case the 
hospital that performed the x-ray would bill for both the x-ray and the 
CAD service. It is unnecessary to treat CPT code 0175T as a ``special'' 
packaged code because generally the payment for the x-ray CAD would be 
bundled into the payment for the chest x-ray. While we have no costs 
from claims data because 0152T was a new CPT code for CY 2006, and 
0174T and 0175T are new codes for CY 2007, we estimate that the CAD 
service requires only modest resources. We expect that a hospital's 
cost per chest x-ray CAD service would largely depend on the volume of 
CAD services provided. To the extent that CAD may be more frequently 
provided in the future to aid in the review of diagnostic chest x-rays 
as its clinical indications evolve, we expect that its cost would also 
be increasingly reflected in the median costs for chest x-ray 
procedures.
    After carefully considering all public comments received on this 
proposal, we are accepting the APC Panel's August 2006 recommendation 
to package new CPT codes 0174T and 0175T for CY 2007 on an interim 
final basis.
    For CY 2007, we proposed to accept the recommendation of the APC 
Panel and maintain the packaged status of CPT code 36500. As noted in 
the CY 2007 OPPS proposed rule (71 FR 49535) we have heard that CPT 
code 36500 is sometimes billed only with its corresponding radiological 
supervision and interpretation code, 75893, but with no other 
separately payable OPPS services. In those cases, the provider would 
not receive any payment. For CY 2006, we accepted the APC Panel's 
recommendation to package both CPT codes 36500 and 75893 and to examine 
claims data. Our initial review of several clinical scenarios submitted 
by the public seemed to suggest that other separately payable 
procedures, such as venography, would likely be billed on the same 
claim. Our claims data indicate that there are usually separately 
payable codes that are billed on claims with CPT codes 36500 and 75893. 
However, we acknowledge that these two codes may occasionally be 
provided without any separately payable procedures. In these uncommon 
instances, the provider historically has not received any payment under 
the OPPS. We also understand that there is a cost associated with 
registering a patient and providing these services. Using CY 2005 
claims, we have approximately 200 single claims for CPT code 75893, 
with a median cost of $269.13. As proposed for CY 2007 and described 
below for ``special'' packaged codes, when CPT codes 36500 and 75893 
are billed on a claim with no separately payable OPPS services, CPT 
code 75893 would become separately payable and would receive payment 
for APC 0668. In this circumstance, payment for CPT code 36500 would be 
packaged into the separate payment for CPT code 75893.
    We received no public comments on our proposal. Therefore, we are 
finalizing our proposal to accept the APC Panel's recommendation to 
maintain the packaged status of CPT code 36500 without modification.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
and pay separately for CPT codes 36540, 36600, 38792, 75893, 94762, and 
96523 when any of these codes appear on a claim with no separately 
payable OPPS services also reported for the same date of service. We 
will refer to this subset of codes as ``special'' packaged codes. We 
acknowledge that there is a cost to the hospital associated with 
registering and treating a patient, regardless of whether the specific 
service provided requires minimal or significant hospital resources. 
While we continue to believe that these ``special'' packaged codes are 
almost always provided along with a separately payable service, our 
claims analyses indicate that there are rare instances when one of 
these services is provided without another separately payable OPPS 
service on the claim for the same date of service. In these instances, 
providers do not currently receive any payment. Therefore, we proposed 
to provide payment for the ``special'' packaged codes listed above when 
they are billed on a claim without another separately payable OPPS 
service on the same date. When any of the ``special'' packaged codes 
are billed with other codes that are separately payable under the OPPS 
on the same date of service, the ``special'' packaged code would be 
treated as a packaged code, and the cost of the packaged code would be 
bundled into the costs of the other separately payable services on the 
claim. The payments that the provider receives for the separately 
payable services would include the bundled payment for the packaged 
code(s).
    During the August 2006 APC Panel meeting, the APC Panel reviewed a 
request from the public to assign payment to CPT code 96523 when it 
appears on a claim with no separately payable OPPS services also 
reported for the same date of service. The Panel

[[Page 67995]]

recommended that we treat CPT code 96523 as a ``special'' packaged code 
for CY 2007.
    We have heard concerns from the public stating that they are unable 
to submit claims to CMS that report only packaged codes. We note that 
although these claims are processed by the OCE and are ultimately 
rejected for payment, they are received by CMS, and we have cost data 
for packaged services based upon these claims. However, we recognize 
that the data used in our analyses to assess the frequencies with which 
packaged services are provided alone and their median costs are 
somewhat limited. It is possible that an unknown number of hospitals 
chose not to submit claims to CMS when a packaged code(s) was provided 
without other separately payable services on their claims, realizing 
that they would not receive payment for those claims. While we have 
been told that some hospitals may bill for a low-level visit if a 
packaged service only is provided so that they receive some payment for 
the encounter, we note that providers should bill a low-level visit 
code in such circumstances only if the hospital provides a significant, 
separately identifiable low-level visit in association with the 
packaged service.
    Through OCE logic, the PRICER would automatically assign payment 
for a ``special'' packaged service reported on a claim if there are no 
other services separately payable under the OPPS on the claim for the 
same date of service. In all other circumstances, the ``special'' 
packaged codes would be treated as packaged services. We assign status 
indicator ``Q'' to these ``special'' packaged codes to indicate that 
they are usually packaged, except for special circumstances when they 
are separately payable. Through OCE logic, the status indicator of a 
``special'' packaged code would be changed either to ``N'' or to the 
status indicator of the APC to which the code is assigned for separate 
payment, depending upon the presence or absence of other OPPS services 
also reported on the claim for the same date. Table 3 included in the 
CY 2007 OPPS proposed rule (71 FR 49536) and shown below listed the 
proposed status indicators and APC assignments for these ``special'' 
packaged codes when they are separately payable. We note that the 
payment for these ``special'' packaged codes is intended to make 
payment for all of the hospital costs, which may include patient 
registration and establishment of a medical record, in an outpatient 
hospital setting even when no separately payable services are provided 
to the patient on that day.
    In the case of a claim with two or more ``special'' packaged codes 
only reported on a single date of service, the PRICER would assign 
separate payment only to the ``special'' packaged code that would 
receive the highest payment. The other ``special'' codes would remain 
packaged and would not receive separate payment.
    Comment: Many commenters complimented the Packaging Subcommittee 
for their efforts to improve payment under the OPPS. In addition, the 
commenters further commended the Packaging Subcommittee and CMS for 
proposing to provide payment for ``special'' packaged codes under 
certain circumstances. One commenter stated that ``special'' packaged 
codes further complicate an already complicated system and requested 
that CMS consistently either package a code or pay separately for a 
code, but not both.
    Response: We appreciate the commenters' support and plan to 
continue working with the Packaging Subcommittee to review other 
packaged codes that are brought to our attention by the public. While 
we acknowledge that ``special'' packaged codes add a layer of 
complexity to a complicated payment system, we continue to believe that 
it is appropriate to assign payment to ``special'' codes under certain 
circumstances. We note the ``special'' packaged code policy should 
impose no additional reporting burden on hospital billing staff because 
the OCE is automatically programmed to assign payment when appropriate.
    Comment: One commenter appreciated that CMS clarified that a 
hospital cannot bill a CPT E/M code simply because the hospital would 
like to receive payment for the packaged service that was provided. The 
commenter asked that CMS also clarify whether this applies only to 
packaged services, or if it also applies to a service for which there 
is no applicable HCPCS code. Another commenter noted that CMS is now 
contradicting Transmittal A-02-129, which states that hospitals can 
bill a low level clinic visit with CPT code 97602 (Removal of 
devitalized tissue from wound(s), non-selective debridement, without 
anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including 
topical application(s), wound assessment, and instruction(s) for 
ongoing care, per session) to receive payment.
    Response: Providers should bill a low-level visit code only if the 
hospital provides a significant, separately identifiable visit from any 
other service provided. This general rule applies to any service 
provided by a hospital. As discussed below in section IX.A, we would 
expect that the hospital resources associated with a visit would be 
reflected in the hospital's internal guidelines used to select the 
level of reporting for the visit. The hospital should bill the clinic 
visit code that most appropriately describes the service provided. We 
acknowledge that Transmittal A-02-129 is based upon our past policy 
that a hospital could bill a low level visit code in addition to CPT 
code 97602, which was then packaged in CY 2003, at the time of the 
instruction. However, beginning in CY 2006 we have provided separate 
payment for CPT 97602 when it is performed as a nontherapy service in 
the hospital outpatient setting. Therefore, the instruction is no 
longer relevant and will be revised, because hospitals are now able to 
report and be paid for this wound care service with the most specific 
CPT code available. This OPPS payment policy for nontherapy, 
nonselective wound care services will continue for CY 2007. In 
circumstances where there is no applicable HCPCS code to describe a 
distinct service, hospitals should continue to report the most 
appropriate unlisted procedure or unlisted services CPT code. In 
summary, with respect to the billing of low level visit CPT codes, as 
described above, our current policy dictates that hospitals may only 
bill a low-level visit code if the hospital provides a significant, 
separately identifiable visit from any other service provided.
    Comment: One commenter thanked CMS for clarifying that CMS receives 
claims with only packaged codes that may be used for data analysis. The 
commenter also stated that it hoped that the ``special'' packaged codes 
policy would convince its hospital billing department to submit claims 
with only packaged services on them, so that CMS would have cost data 
for these codes. Other commenters asked that CMS clarify that it 
receives claims with only packaged codes and no separately payable 
codes.
    Response: We will clarify again that claims with only packaged 
codes are received and processed by the OCE. We can access cost data 
for all of the packaged codes on the claim. We encourage hospitals to 
continue to submit claims to CMS with only packaged codes because these 
submissions will allow us to continue to gather cost data for these 
codes, and help us determine whether it would be appropriate to add 
additional packaged codes to the ``special'' packaged codes list.

[[Page 67996]]

    After carefully considering the public comments received, we are 
adopting without modification, our proposal to accept the APC Panel's 
March 2006 recommendation to treat CPT codes 36540, 36600, 38792, 
75893, 94762, and 96523 as ``special'' packaged codes. We note that we 
also are adopting the APC Panel's August 2006 recommendation to treat 
CPT code 96523 as a ``special'' packaged code. The APC assignments for 
these codes are shown in Table 3 below. These codes are assigned status 
indicator ``Q'' in Addendum B to this final rule with comment period.

               Table 3.--Status Indicators and APC Assignments for ``Special'' Packaged CPT Codes
----------------------------------------------------------------------------------------------------------------
                                                                                                    CY 2007 APC
         CPT code                   Descriptor           CY 2007 APC       Status  indicator          median
----------------------------------------------------------------------------------------------------------------
36540.....................  Collect blood, venous                0624  S........................          $31.44
                             access device.
36600.....................  Arterial puncture;                   0035  T........................           12.22
                             withdrawal of blood for
                             diagnosis.
38792.....................  Sentinel node                        0389  S........................           84.05
                             identification.
75893.....................  Venous sampling through              0668  S........................          381.71
                             catheter, with or
                             without angiography,
                             radiological supervision
                             and interpretation.
94762.....................  Noninvasive ear or pulse             0443  X........................           63.61
                             oximetry for oxygen
                             saturation by continuous
                             overnight monitoring.
96523.....................  Irrigation of implanted              0624  S........................           31.44
                             venous access device.
----------------------------------------------------------------------------------------------------------------

    We will monitor and analyze the claims frequency and claims detail 
for situations in which these codes are billed alone and then 
separately paid. This will allow us to determine both which providers 
are billing these codes most often and under what circumstances these 
codes are billed and separately paid. We expect that hospitals 
scheduling and providing services efficiently to Medicare beneficiaries 
will continue to generally provide these minor services in conjunction 
with other medically necessary services.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
and maintain the packaged status of CPT codes 74328, 74329, and 74330. 
The AMA notes that these radiological supervision and interpretation 
codes should be reported with procedure CPT codes 43260-43272. In fact, 
our data indicate that these supervision and interpretation codes are 
billed with 43260-43272 more than 90 percent of the time, indicating 
their routine use. We believe that some providers may be concerned that 
although the payment for the endoscopic procedure includes the bundled 
payment for the supervision and interpretation performed by the 
radiology department, the payment for the comprehensive service may be 
directed to the hospital department that performed the endoscopic 
procedure, rather than to the radiology department. While we understand 
this concern, the OPPS pays hospital for services provided, and we 
believe that hospitals are responsible for attributing payments to 
hospital departments as they believe appropriate. We do not believe 
that packaging these radiological supervision and interpretation codes 
leads to inaccurate payments for the full hospital resources associated 
with endoscopic retrograde cholangiopancreatography procedures.
    We received no public comments on our proposal. Therefore, we are 
adopting our proposal to accept the APC Panel's recommendation and 
maintain the packaged status of CPT codes 74328, 74329, and 74330 for 
CY 2007.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
to continue to package CPT codes 76001, 76003, and 76005 and to 
continue to pay separately for CPT code 76000. As noted in the CY 2007 
proposed rule (71 FR 49536), we received a comment which stated that it 
was inconsistent to pay separately for CPT code 76000 but to package 
CPT code 76001, when CPT code 76001 appears to be a similar code, 
except that it is for a longer period of physician time. The Packaging 
Subcommittee believed that many of the claims that listed CPT code 
76001 were erroneously billed, as many of the procedure codes that were 
billed with CPT code 76001 included fluoroscopy as an integral part of 
the procedure. In other cases, the Packaging Subcommittee noted that a 
procedure-specific fluoroscopy code should probably have been billed, 
instead of CPT code 76001. The Packaging Subcommittee believed that CPT 
code 76000 could often be provided as a sole service, with no other 
separately payable procedures. The Packaging Subcommittee recommended 
that CMS continue to pay separately for CPT code 76000, consistent with 
the AMA's definition of this code, which specifies that it is a 
separate procedure, and to continue to package CPT codes 76001, 76003, 
and 76005.
    We received no public comments that objected to our proposal. 
Therefore, we are adopting our proposal, without modification, to 
accept the APC Panel's recommendation to continue to package CPT codes 
76001, 76003, and 76005 and to continue to pay separately for CPT code 
76000 for OPPS services furnished on or after January 1, 2007.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
to continue to package CPT codes 76937 and 75998. In the CY 2006 OPPS 
final rule with comment period (70 FR 68544 and 68545), we reviewed in 
detail the data related to these two codes and promised to share CY 
2004 and early CY 2005 data with the Packaging Subcommittee. We 
reviewed current data with the Packaging Subcommittee, and it 
recommended that we continue to package these codes. In summary, we 
believe that these services would always be provided with another 
separately payable procedure, so their costs would be appropriately 
bundled with the definitive vascular access device procedures. We found 
that the costs for these guidance procedures are relatively low 
compared to the CY 2007 proposed payment rates for the separately 
payable services they most frequently accompany. If we were to 
unpackage CPT codes 76937 and 75998, the single bills available to 
develop median costs for vascular access device insertion services 
would be significantly reduced. Therefore, we proposed to continue to 
package both CPT codes 76937 and 75998 for CY 2007.
    CPT code 75998 will be replaced with CPT code 77001, effective 
January 1, 2007. The code descriptor will remain the same.
    Comment: Several commenters requested that CMS pay separately for 
CPT code 76937 because they believe that packaged payment creates a 
disincentive for use of this technology. Three commenters cited a June 
2001 report published by the Agency for Healthcare Research and Quality 
that claims that use of ultrasound guidance reduced the relative risk 
for complications during a central venous

[[Page 67997]]

catheter insertion. In addition, two commenters submitted claims data 
analyses that suggested that for those vascular access procedures that 
CPT code 76937 could be reported with, CPT code 76937 was reported, on 
average, only 14 percent of the time, with the greatest utilization 
rate no more than 25 percent. The commenters stated that these analyses 
confirmed that ultrasound guidance is not standard practice while 
performing vascular access procedures.
    Response: We appreciate the data analyses submitted by the 
commenters. In fact, we published the results of our similar analysis 
in the CY 2006 final rule with comment period (70 FR 68544). To 
summarize our previous analysis, using CY 2004 single claims data, we 
determined that for the four most commonly billed venous access device 
insertion codes (CPT codes 36556, 36558, 36561, and 36569), one or more 
forms of guidance (fluoroscopic and/or ultrasound) were reported on 41 
to 64 percent of the single claims utilized for ratesetting. 
Specifically, ultrasound guidance was reported from 16 to 34 percent of 
the time and fluoroscopic guidance was billed from 29 to 52 percent of 
the time. Thus, overall for these vascular access device insertion 
services, guidance was used in at least 41 percent of the single claim 
cases, a very significant portion of the time. We note that all of the 
commenters are specifically concerned about unpackaging CPT code 76937 
and do not appear to be concerned with the packaged status of CPT 
75998. In fact, the commenters' analyses only included ultrasound 
guidance and did not specify the number of venous access device 
insertions that involved fluoroscopic guidance. We believe that 
hospital staff choose whether to use no guidance or fluoroscopic 
guidance or ultrasound guidance on an individual basis, depending on 
the clinical circumstances of the vascular access device insertion 
procedure. We also note that the two commenters studied the frequency 
of CPT code 76937 when billed with CPT codes 36555-36585, which 
includes central venous access device insertions, repairs, and 
replacements. In fact, the study that the commenters reference 
indicates that ultrasound guidance is appropriate for central venous 
access device insertions. Interestingly, the data now show that 16 
percent of all central venous access device insertions are billed with 
ultrasound guidance while only 2 percent of repairs and replacements 
are billed with ultrasound guidance. We believe that this indicates 
that it may be less useful to use ultrasound guidance in conjunction 
with central venous access device repairs and replacements. Our 
hospital claims data demonstrate that in CY 2004 guidance services were 
used frequently for the insertion of vascular access devices, and we 
have no evidence that patients lacked appropriate access to guidance 
services necessary for the safe insertion of vascular access devices in 
the hospital outpatient setting. To the extent that ultrasound guidance 
may be more frequently provided in the future in association with the 
insertions of venous access devices or other OPPS services, we expect 
that its cost would also be increasingly reflected in the median costs 
for those services.
    Also in the CY 2006 final rule (FR 70 68544), we reported our 
analysis of claims data related to ultrasound guidance for vascular 
access device insertion procedures from another perspective. Rather 
than determining how often central venous access device insertions were 
billed with ultrasound guidance, we determined how often ultrasound 
guidance was billed with central venous access device insertions. The 
OPPS hospital claims data reviewed at that time revealed that out of 
the total instances of CPT code 76937 appearing on the claims used for 
setting payment rates for CY 2006, CPT code 76937 was billed with four 
separately payable codes for insertion of central venous access devices 
84 percent of the time. This indicated, as might have been expected, 
that the costs for CPT code 76937 were typically packaged into payment 
for four CPT codes, 36566, 36558, 36561, and 36569, the most commonly 
billed codes under the OPPS for vascular access device insertion. 
Because we believe that ultrasound guidance would always be provided 
with another separately payable procedure, its costs would be 
appropriately bundled with the handful of vascular access device 
insertion procedures with which it is most commonly performed. In 
addition, packaging is also appropriate because the cost of ultrasound 
guidance is relatively low compared to the CY 2007 payment rates for 
the separately payable services it most frequently accompanies.
    After carefully considering the public comments received, we are 
adopting our proposal without modification to accept the APC Panel's 
March 2006 recommendation to continue to package CPT codes 76937 and 
77001, which replaces CPT code 75998.
    For CY 2007, we proposed to accept the APC Panel's recommendation 
to continue to package HCPCS code G0269. This code should never be 
billed without another separately payable procedure. Recent data 
indicate that 94 percent of the time HCPCS code G0269 was billed with 
either CPT code 93510 (Left heart catheterization, retrograde, from the 
brachial artery, axillary artery or femoral artery; percutaneous) or 
93526 (Combined right heart catheterization and retrograde left heart 
catheterization). In addition, the median cost of G0269 is low compared 
to the costs of the procedures with which it is typically associated.
    We received no public comments on our proposal. Therefore, we are 
finalizing our proposal, without modification, to package HCPCS code 
G0269 for CY 2007.
    For CY 2007, we proposed to continue packaging CPT codes 94760 and 
94761 and not adopt the APC Panel's recommendation to provide separate 
payment for these services if there are no other separately payable 
OPPS services on the claim for the same date of service. Our data 
review revealed that these services are very frequently provided in the 
OPPS, with over 1.18 million claims in CY 2005 for the single pulse 
oximetry determination service and over 485,000 claims for the multiple 
determinations service. These high frequencies may actually be 
understated as both of these services are packaged codes, and we have 
been told that some hospitals may not report the HCPCS codes for 
services for which they receive no separate payments. Single and 
multiple pulse oximetry determinations are almost always provided in 
association with other services that are separately payable under the 
OPPS, into which their costs may be appropriately packaged. 
Specifically, OPPS hospital claims data revealed that out of the total 
instances of CPT code 94760 appearing on claims used for setting 
payment rates for this CY 2007 OPPS final rule with comment period, CPT 
code 94760 was billed only 4 percent of the time in association with no 
other separately payable OPPS services, with a median cost of $14. 
Using the same data, CPT code 94761 was billed only 7 percent of the 
time in association with no other separately payable OPPS services, 
with a median cost of $36. These pulse oximetry services have a 
relatively low cost compared with the OPPS services they frequently 
accompany. If we were to provide separate payment for these pulse 
oximetry determinations when performed as stand alone procedures by 
hospitals, we are concerned that hospitals would lose their incentive 
to provide these basic, low cost, and brief services as efficiently as 
possible, generally during the same encounters where they are providing 
other services to the same patients. We believe their

[[Page 67998]]

appropriate provision as single services should be very rare. 
Therefore, for CY 2007 we proposed not to include these codes on the 
list of ``special'' packaged codes, so their payment would remain 
packaged in all circumstances.
    We received no public comments on our proposal. Therefore, we are 
adopting our proposal to continue packaging CPT codes 94760 and 94761 
and are not adopting the APC Panel's March 2006 recommendation to 
provide separate payment for these services if there are no other 
separately payable OPPS services on the claim for the same date of 
service.
    For CY 2007, we proposed to assign status indicator ``A'' to HCPCS 
code P9612 and reject the APC Panel's recommendation to pay separately 
under the OPPS for this code when it is billed without any separately 
payable OPPS services. This code is currently payable on the clinical 
lab fee schedule. Its status indicator of ``A'' would provide payment 
for the service whenever it is billed, regardless of the presence or 
absence of other reported services. In addition, for consistency we are 
proposing to assign status indicator ``A'' to HCPCS code P9615 as it is 
also payable on the clinical lab fee schedule. In general, when a code 
is payable on the clinical lab fee schedule, we defer to that fee 
schedule and do not assign payment under the OPPS.
    We received no public comments on our proposal. Therefore, we are 
adopting our proposal without modification to assign status indicator 
``A'' to HCPCS code P9612 and reject the APC Panel's recommendation to 
pay separately under the OPPS for this code when it is billed without 
any separately payable OPPS services.
    For CY 2007, we proposed to assign status indicator ``N'' to CPT 
code 0126T (Common carotid intima-media thickness (IMT) study for 
evaluation of atherosclerotic burden or coronary heart disease risk 
factor). We received one public comment on this proposal.
    Comment: One commenter disagreed with our status indicator 
assignment of ``N'' for CPT code 0126T and stated that CMS should pay 
separately for the common carotid IMT procedure because this is often 
the sole service that is performed in the hospital outpatient setting. 
As clarified by the commenter, common carotid IMT is a standardized 
ultrasound procedure that enables physicians to safely and accurately 
measure and monitor atherosclerosis, which is the underlying cause of 
heart attacks and stroke. The commenter reported that this code became 
effective on January 1, 2006. According to the commenter, unlike 
certain other ultrasound procedures that must be provided with other 
services, common carotid IMT is a stand-alone diagnostic test because 
it requires special imaging of the arterial wall and quantitative 
analysis. The commenter further added that based on the CPT code book 
instruction for other carotid procedures (that is, CPT codes 93880 and 
93882), CPT coding does not permit bundling of 0126T with other 
procedure codes. The commenter urged CMS to pay separately for common 
carotid IMT and assign this code to New Technology APC 1504--Level IV 
($200-$300), with a payment rate of $250.
    Response: We continue to believe that it would be unlikely for this 
code to be provided without any other separately payable services on 
the same day. However, we also think that the commenter's suggestion 
bears closer examination. Therefore, we will review this code with the 
Packaging Subcommittee of the APC Panel, as is our standard procedure 
for codes that we are asked to review during the comment period, and as 
we have previously done for the other services discussed above. We will 
discuss with the Packaging Subcommittee, on an ongoing basis, packaged 
procedures for which status indicator changes have been suggested by 
the public.
    We note that the APC Panel Packaging Subcommittee remains active, 
and additional issues and new data concerning the packaging status of 
codes will be shared for its consideration as information becomes 
available. We continue to encourage submission of common clinical 
scenarios involving currently packaged HCPCS codes to the Packaging 
Subcommittee for its ongoing review. Additional detailed suggestions 
for the Packaging Subcommittee should be submitted to 
[email protected], with ``Packaging Subcommittee'' in the subject 
line.

B. Payment for Partial Hospitalization

1. Background
    Partial hospitalization is an intensive outpatient program of 
psychiatric services provided to patients as an alternative to 
inpatient psychiatric care for beneficiaries who have an acute mental 
illness. A partial hospitalization program (PHP) may be provided by a 
hospital to its outpatients or by a Medicare-certified community mental 
health center (CMHC). Section 1833(t)(1)(B)(i) of the Act provides the 
Secretary with the authority to designate the hospital outpatient 
services to be covered under the OPPS. The Medicare regulations at 42 
CFR 419.21(c) that implement this provision specify that payments under 
the OPPS will be made for partial hospitalization services furnished by 
CMHCs. Section 1883(t)(2)(C) of the Act requires that we establish 
relative payment weights based on median (or mean, at the election of 
the Secretary) hospital costs determined by 1996 claims data and data 
from the most recent available cost reports. Payment to providers under 
the OPPS for PHPs represents the provider's overhead costs associated 
with the program. Because a day of care is the unit that defines the 
structure and scheduling of partial hospitalization services, we 
established a per diem payment methodology for the PHP APC, effective 
for services furnished on or after August 1, 2000. For a detailed 
discussion, we refer readers to the April 7, 2000 OPPS final rule with 
comment period (65 FR 18452).
    Historically, the median per diem cost for CMHCs has greatly 
exceeded the median per diem cost for hospital-based PHPs and has 
fluctuated significantly from year to year while the median per diem 
cost for hospital-based PHPs has remained relatively constant ($200-
$225). We believe that CMHCs may have increased and decreased their 
charges in response to Medicare payment policies. As discussed in more 
detail in section II.B.2. of the preamble of this final rule with 
comment period and in the CY 2004 OPPS final rule with comment period 
(68 FR 63470), we believe that some CMHCs manipulated their charges in 
order to inappropriately receive outlier payments.
    In the CY 2003 OPPS update, the difference in median per diem cost 
for CMHCs and hospital-based PHPs was so great, $685 for CMHCs and $225 
for hospital-based PHPs, that we applied an adjustment factor of .583 
to CMHC costs to account for the difference between ``as submitted'' 
and ``final settled'' cost reports. By doing so, the CMHC median per 
diem cost was reduced to $384, resulting in a combined hospital-based 
and CMHC PHP median per diem cost of $273. As with all APCs in the 
OPPS, the median cost for each APC was scaled relative to the cost of a 
mid-level office visit and the conversion factor was applied. The 
resulting per diem rate for PHP for CY 2003 was $240.03.
    In the CY 2004 OPPS update, the median per diem cost for CMHCs grew 
to $1,038, while the median per diem cost for hospital-based PHPs was 
again $225. After applying the .583 adjustment factor in the CY 2004 
proposed rule to the median CMHC per diem cost, the median CMHC per 
diem cost was $605. Because the CMHC median per diem cost exceeded the

[[Page 67999]]

average per diem cost of inpatient psychiatric care, we proposed a per 
diem rate for CY 2004 based solely on hospital-based PHP data. The 
proposed PHP per diem for CY 2004, after scaling, was $208.95. However, 
by the time we published the OPPS final rule with comment period for CY 
2004, we had received updated CCRs for CMHCs. Using the updated CCRs 
significantly lowered the CMHC median per diem cost to $440. As a 
result, we determined that the higher per diem cost for CMHCs was not 
due to the difference between ``as submitted'' and ``final settled'' 
cost reports, but was the result of excessive increases in charges 
which may have been done in order to receive higher outlier payments. 
Therefore, in calculating the PHP median per diem cost for CY 2004, we 
did not apply the .583 adjustment factor to CMHC costs to compute the 
PHP APC. Using the updated CCRs for CMHCs, the combined hospital-based 
and CMHC median per diem cost for PHP was $303. After scaling, we 
established the CY 2004 PHP APC of $286.82.
    For CY 2005, the PHP per diem amount was based on 12 months of 
hospital and CMHC PHP claims data (for services furnished from January 
1, 2003, through December 31, 2003). We used data from all hospital 
bills reporting condition code 41, which identifies the claim as 
partial hospitalization, and all bills from CMHCs because CMHCs are 
Medicare providers only for the purpose of providing partial 
hospitalization services. We used CCRs from the most recently available 
hospital and CMHC cost reports to convert each provider's line-item 
charges as reported on bills, to estimate the provider's cost for a day 
of PHP services. Per diem costs were then computed by summing the line-
item costs on each bill and dividing by the number of days on the bill.
    In a Program Memorandum issued on January 17, 2003 (Transmittal A-
03-004), we directed fiscal intermediaries to recalculate hospital and 
CMHC CCRs by April 30, 2003, using the most recently settled cost 
reports. Following the initial update of CCRs, fiscal intermediaries 
were further instructed to continue to update a provider's CCR and 
enter revised CCRs into the outpatient provider-specific file. 
Therefore, for CMHCs, we used CCRs from the outpatient provider-
specific file.
    In the CY 2005 OPPS update, the CMHC median per diem cost was $310 
and the hospital-based PHP median per diem cost was $215. No 
adjustments were determined to be necessary and, after scaling, the 
combined median per diem cost of $289 was reduced to $281.33. We 
believed that the reduction in the CMHC median per diem cost indicated 
that the use of updated CCRs had accounted for the previous increase in 
CMHC charges, and represented a more accurate estimate of CMHC per diem 
costs for PHP.
    For the CY 2006 OPPS final rule with comment period, we analyzed 12 
months of the most current claims data available for hospital and CMHC 
PHP services furnished between January 1, 2004, and December 31, 2004. 
We also used the most currently available CCRs to estimate costs. The 
median per diem cost for CMHCs was $154, while the median per diem cost 
for hospital-based PHPs was $201. Based on the CY 2004 claims data, the 
average charge per day for CMHCs was $760, considerably greater than 
hospital-based per day costs but significantly lower than what it was 
in CY 2003 ($1,184). We believed that a combination of reduced charges 
and slightly lower CCRs for CMHCs resulted in a significant decline in 
the CMHC median per diem cost between CY 2003 and CY 2004.
    Following the methodology used for the CY 2005 OPPS update, the CY 
2006 OPPS update combined hospital-based and CMHC median per diem cost 
was $161, a decrease of 44 percent compared to the CY 2005 combined 
median per diem amount. We believed that this amount was too low to 
cover the cost for all PHPs.
    Therefore, as stated in the CY 2006 OPPS final rule with comment 
period (70 FR 68548 and 68549), we considered the following three 
alternatives to our update methodology for the PHP APC for CY 2006 to 
mitigate this drastic reduction in payment for PHP services: (1) base 
the PHP APC on hospital-based PHP data alone; (2) apply a different 
trimming methodology to CMHC costs in an effort to eliminate the effect 
of data for those CMHCs that appeared to have excessively increased 
their charges in order to receive outlier payments; and (3) apply a 15-
percent reduction to the combined hospital-based and CMHC median per 
diem cost that was used to establish the CY 2005 PHP APC. (We refer 
readers to the CY 2006 OPPS final rule with comment period for a full 
discussion of the three alternatives (70 FR 68548).) After carefully 
considering these three alternatives and all comments received on them, 
we adopted the third alternative for CY 2006. We adopted this 
alternative because we believed and continue to believe that a 
reduction in the CY 2005 median per diem cost would strike an 
appropriate balance between using the best available data and providing 
adequate payment for a program that often spans 5-6 hours a day. We 
believe that 15 percent is an appropriate reduction because it 
recognizes decreases in median per diem costs in both the hospital data 
and the CMHC data, and also reduces the risk of any adverse impact on 
access to these services that might result from a large single-year 
rate reduction. However, we adopted this policy as a transitional 
measure, and stated in the CY 2006 OPPS final rule with comment period 
that we would continue to monitor CMHC costs and charges for these 
services and work with CMHCs to improve their reporting so that 
payments can be calculated based on better empirical data, consistent 
with the approach we have used to calculate payments in other areas of 
the OPPS (70 FR 68548).
    To apply this methodology for CY 2006, we reduced $289 (the CY 2005 
combined unscaled hospital-based and CMHC median per diem cost) by 15 
percent, resulting in a combined median per diem cost of $245.65 for CY 
2006.
2. PHP APC Update for CY 2007
    For CY 2007, we proposed to calculate the CY 2007 PHP per diem 
payment rate using the same update methodology that we adopted in CY 
2006. That is, we proposed to apply an additional 15-percent reduction 
to the combined hospital-based and CMHC median per diem cost that was 
used to establish the CY 2006 per diem PHP payment.
    As discussed in the CY 2007 OPPS proposed rule (71 FR 49538), we 
analyzed 12 months of data for hospital and CMHC PHP claims for 
services furnished between January 1, 2005, and December 31, 2005. We 
used the most currently available CCRs to estimate costs. Using these 
CY 2005 claims data, the median per diem cost for CMHCs was $165 and 
the median per diem cost for hospital-based PHPs was $209. Following 
the methodology used for the CY 2005 update, the CY 2007 combined 
hospital-based and CMHC median per diem cost is $172.
    While the combined hospital-based and CMHC median per diem cost is 
about $10 higher using the CY 2005 data compared to the CY 2004 data 
($172 compared to $161), we believe this amount is still too low to 
cover the cost for PHPs. As a result, we proposed the same policy we 
adopted for CY 2006--a 15-percent reduction applied to the current 
median cost. Therefore, to calculate the proposed PHP per diem rate for 
CY 2007, we applied an additional 15-percent reduction to the

[[Page 68000]]

combined hospital-based and CMHC median per diem cost.
    To calculate the proposed CY 2007 APC PHP per diem cost, we reduced 
$245.65 (the CY 2005 combined hospital-based and CMHC median per diem 
cost of $289 reduced by 15 percent) by 15 percent, which resulted in a 
proposed combined median per diem cost of $208.80.
    We received numerous public comments in response to our proposal. A 
summary of the comments received and responses follow:
    Comment: A number of commenters expressed concern about the 
magnitude of the reduction, particularly in light of last year's 15 
percent reduction. The majority of commenters requested that CMS freeze 
the PHP rate at the CY 2006 level. Representatives of CMHCs argued that 
their costs are higher than those of hospitals, with most in the $300 
to $400 range. Another commenter indicated that a per-day rate of $325 
to $375 was more appropriate than the proposed amount. The commenters 
also suggested alternatives to calculating the PHP rate, such as 
including prior years' CMHC data trended forward based on medical 
inflation or market basket update. In addition, several patients were 
concerned that a 15-percent reduction in payment would negatively 
impact their ability to continue therapy.
    Response: For this CY 2007 final rule with comment period, we 
analyzed 12 months of more current data for hospital and CMHC PHP 
claims for services furnished between January 1, 2005 and December 31, 
2005. These claims data are more current because the data include 
claims paid through June 30, 2006. We also used the most currently 
available CCRs to estimate costs. Using these updated data, we 
recreated the analysis performed for the CY 2007 proposed rule to 
determine if the significant factors we used in determining the 
proposed PHP rate had changed. The median per diem cost for CMHCs 
increased $8 to $173, while the median per diem cost for hospital-based 
PHPs decreased $19 to $190. The CY 2005 average charge per day for 
CMHCs was $675 similar to the figure noted in the CY 2007 proposed rule 
($673) but still significantly lower than what is noted for CY 2003 
($1,184).
    Following the 15-percent reduction methodology used for the CY 2005 
update, the combined hospital-based and CMHC median per diem cost would 
be $175, only slightly more than the figure noted in the CY 2007 
proposed rule ($172). We continue to believe this amount is too low to 
cover the cost of PHPs. However, we believe that freezing the current 
rate would not reflect the downward trend in data. Although the data 
continue to show a low per diem cost for PHP, we believe that a 
transition to the reduced amount may be more appropriate to ensure 
access for the vulnerable population served in PHPs. We recognize that 
many CMHCs are located in areas affected by Hurricanes Katrina and Rita 
where access to intensive mental health treatment is now limited. We 
note that the median per diem cost for hospital-based PHPs, which has 
been in the $200 to $225 range since the OPPS was implemented, went 
from $201 in CY 2004 to $190 in CY 2005, a decrease of 5 percent. We 
believe this percentage decrease provides a valid transitional 
percentage measure reflecting the downward trend in PHP cost.
    Therefore, for CY 2007, we are making a 5-percent reduction to the 
CY 2006 median per diem rate. This amount accounts for the downward 
direction of the data and addresses concerns about the magnitude of a 
15-percent reduction in 1 year. To calculate the CY 2007 APC PHP per 
diem cost, we reduced $245.65 (the CY 2005 combined hospital-based and 
CMHC median per diem cost of $289 reduced by 15 percent) by 5 percent, 
which resulted in a combined per diem cost of $233.37. If the PHP per 
diem cost continues to be low in CY 2008, we expect to continue the 
transition of decreasing the PHP median per diem cost to an amount that 
is reflective of the PHP data.
    Comment: The commenters requested that CMS better define how it is 
monitoring and working with CMHCs to improve their reporting.
    Response: CMS has provided guidance to all providers, through 
transmittals and manuals. In addition, when necessary, CMS has worked 
closely with fiscal intermediaries to provide guidance to targeted PHP 
providers to improve reporting.
    Comment: Several commenters stated that CMS has applied its own 
assumptions and methodology on a different basis to compute the PHP 
rate each year from CY 2003 to CY 2006. The commenters also stated that 
the only years CMS used the same method was CY 2006 and CY 2007, when 
CMS made a simple 15-percent reduction from the previous year's rate.
    Response: We do not agree with the commenters' assessment of our 
methodology for computing the PHP median per diem cost. Although a 
0.583 adjustment factor was applied to CMHC costs in the CY 2003 
update, all other aspects of the methodology that the commenter 
referenced have been the same each year until CY 2006. We have 
consistently calculated the PHP median per diem cost by using combined 
hospital-based and CMHC median cost data and scaled the figure relative 
to the cost of a mid-level office visit and then applied the conversion 
factor. However, in CY 2006, the combined hospital-based and CMHC 
median cost data produced an amount we believed was so low that it 
would result in too large of a single year rate reduction that we 
modified our methodology by limiting this decrease to 15 percent.
    Comment: One commenter replicated the CMS methodology and computed 
rates very close to the CY 2007 proposed per diem rate, as well as the 
separate median per diem costs for CMHCs and hospital-based PHPs. The 
commenter also created a 3-year rolling median cost that also resulted 
in a rate similar to the proposed PHP rate. However, the commenter 
recommended that CMS use the hospital-specific cost center CCR for 
partial hospitalization instead of the overall outpatient CCR to 
calculate PHP median costs. The commenter believed that CMS has 
understated the PHP median costs by not using the hospital-specific 
CCRs for partial hospitalization.
    Response: We note that most hospitals do not have a cost center for 
partial hospitalization; therefore, we have used the CCR as specific to 
PHP as possible. The following link contains the Revenue Cost to Cost 
Center Crosswalk: http://www.cms.hhs.gov/HospitalOutpatientPPS/03_crosswalk.asp#TopOfPage.
    This crosswalk indicates how (and if) charges on a claim are mapped 
to a cost center for the purpose of converting charges to cost. One or 
more cost centers are listed for every revenue code that is used in the 
OPPS median calculations, starting with most specific, and ending with 
most general. CMS maps the revenue code to the most specific cost 
center with a provider-specific CCR. If the hospital does not have a 
CCR for any of the listed cost centers, the overall hospital CCR is the 
default. The PHP revenue centers are mapped to a Primary Cost Center 
3550 ``Psychiatric/Psychological Services.'' If that cost center is not 
available, then the Secondary Cost Center is 6000 ``Clinic.'' We use 
the overall facility CCR for CMHCs because PHP is the CMHCs' only 
Medicare cost and CMHCs do not have the same cost centers as hospitals. 
Therefore, for CMHCs, we use the CCR from the outpatient provider-
specific file.
    Comment: One commenter stated that its internal computations 
reflect PHP per diem costs of $262.82 for its facility. The commenter 
urged CMS to increase the CY 2006 PHP rate of $245.65 by 6.8 percent so 
that the commenter's

[[Page 68001]]

program would break even. Another commenter questioned why CMS did not 
use actual cost report data to obtain true costs instead of estimating 
cost using CCRs applied to charges. A third commenter stated that CMS 
is required to include average costs for all providers and that CMS 
claims to utilize data representative of the mean of actual operating 
costs.
    Response: We appreciate the commenter sharing its facility's per 
diem costs for its facility. However, PHP providers are paid under the 
OPPS. Under the OPPS, we generally determine rates based on median cost 
using charges from bill data and then estimate costs using CCRs. The 
OPPS is a PPS and will reflect generally the cost of providing 
services. A PPS may pay more or less than a provider's costs and is not 
a reasonable cost reimbursement system.
    Comment: One commenter observed a decline of 19 percent in the 
number of hospital-based PHPs from CY 2003 to CY 2005 and a decline of 
21 percent in the number of hospital-based PHP claims. The commenter 
expected further reductions in the number of hospital-based PHPs if CMS 
implements the proposed 15-percent rate cut in CY 2007.
    Response: We do not believe this is an appropriate comparison 
because the commenter did not use the complete year of CY 2005 claims 
data. Rather, the commenter used CY 2005 claims processed through 
December 31, 2005. Using comparable CYs 2003 and 2005 data, (both CY 
2003 and CY 2005 claims processed through June 30, 2004 and June 30, 
2006, respectively), the declines are 11 percent and 5 percent, 
respectively. During the same time period, the number of CMHCs 
increased 13 percent and the number of CMHC PHP claims increased 36 
percent. While there may have been fewer hospital-based PHPs, the 
number of CMHCs increased from 136 in CY 2003 to 179 in CY 2005. In CY 
2005, CMHC and hospital-based PHPs combined provided 1.2 million days 
of PHP care, compared to approximately 0.8 million days of PHP care in 
CY 2003. We believe our payment rates continue to ensure adequate 
access to PHP care.
    Comment: Several commenters suggested establishing a task force to 
develop a new rate methodology that captures all relevant data and 
reflects the actual costs to providers to deliver PHP services. The 
commenters recommended that the new ratesetting task force be composed 
of CMS staff and a diverse group of stakeholders that include front-
line providers of PHP services and representatives from national 
industry organizations.
    Response: We agree that the payment rate for PHP needs to be 
accurate and appropriate to sustain access to care. As we consider 
changes to the current methodology, we believe input from the industry 
is an important part of that process. Therefore, we welcome any input 
and information that the industry can provide about the costs of their 
programs and encourage providers to submit information on their costs. 
We note that any significant change in payment methodology would 
require a statutory change.
    Comment: A few commenters stated that wage index adjustment does 
not accurately reflect the cost of labor in areas affected by 
Hurricanes Katrina and Rita.
    Response: The hospital wage data used to compute the FY 2007 
hospital wage index is from the FY 2003 hospital cost reports for all 
hospitals. This is the standard lag timeframe in determining the 
hospital wage index. It will be another 2 years before the FY 2005 data 
will be reflected in the FY 2009 hospital wage index. The wage index is 
a relative measure of differences in area hourly wage levels. It 
compares a labor market's average hourly wage to the national average 
hourly wage. To the extent that post-hurricane hospital labor costs are 
higher relative to the national average, the wage index will reflect 
the higher relative labor cost beginning when the FY 2005 data will be 
used in the FY 2009 IPPS hospital wage index (which will be applied to 
the CY 2009 OPPS rate year). In addition, the statutory authority for 
the OPPS wage index policy in section 1833(t)(2)(D) of the Act requires 
that wage adjustments be made in a budget neutral manner. Therefore, we 
cannot raise one wage area and still maintain budget neutrality.
    Comment: A few commenters disagreed with the CMS approach to 
establishing the median per diem cost by summarizing the line-item 
costs on each bill and dividing by the number of days on the bills. The 
commenters indicated that this calculation can severely dilute the rate 
and penalize providers. The commenters stated that all programs are 
strongly encouraged by the fiscal intermediaries to submit all PHP 
service days on claims, even when the patient receives less than three 
services. They further stated that programs must report these days to 
be able to meet the 57 percent attendance threshold and avoid potential 
delays in the claim payment. The commenters were concerned that 
programs are only paid their per diem when three or more qualified 
services are presented for a day of service. The commenters stated that 
if only one or two services are assigned a cost and the day is divided 
into the aggregate data, the cost per day is significantly compromised 
and diluted. They claimed that even days that are paid but only have 
three services dilute the cost factors on the calculations.
    Response: If a provider has charges on a bill for which they do not 
receive payment, this will be reflected in that provider's CCRs. This 
lower CCR will be applied to the larger charges and will result in the 
appropriate cost per diem. To gauge the effect that days with one or 
two services had on the per diem cost, we trimmed all days with less 
than three services, and the recalculated median per diem cost only 
increased by $4.00. As such, we do not believe the calculations are 
adversely affected by the inclusion of these days.
    Comment: A few commenters expressed concern that their financial 
status is affected where States limit payment of beneficiary 
coinsurance if the amount of Medicare payment made to a provider 
exceeds the State's payment rate for PHP.
    Response: This is a Medicaid issue and beyond the scope of this 
final rule.
    Comment: With respect to the methodology used to establish the PHP 
APC amount, commenters were concerned that data from settled cost 
reports fails to include costs reversed on appeal. The commenters 
stated that there are inherent problems in using claims data from a 
different time period than the CCRs from settled cost reports. The 
commenters indicated this would artificially lower the computed median 
costs, even though when cost reports are settled, generally 2 years or 
more after the actual year of services, as the providers have operated 
on actual revenues of 80 percent of the per diem.
    Response: We use the best available data in computing the APCs. We 
issued a Program Memorandum on January 17, 2003 directing fiscal 
intermediaries to update the CCRs on an on-going basis whenever a more 
recent full year cost report is available. In this way, we minimize the 
time lag between the CCRs and claims data and continue to use the best 
available data.
    Comment: One commenter stated that administrative costs for CMHCs 
continue to be a major impediment to operating PHPs for Medicare 
beneficiaries. The commenter was concerned that Medicare does not cover 
transportation to and from programs and does not cover meals. The 
commenter stated that almost all programs offer transportation because 
in most cases

[[Page 68002]]

Medicare beneficiaries with serious mental illnesses would not be able 
to access these programs without the transportation.
    Response: The services that are covered as part of a PHP are 
specified in section 1861(ff) of the Act. Meals and transportation are 
specifically excluded under section 1861(ff)(2)(I) of the Act.
    Comment: Several commenters summed the payment rate for four Group 
Therapy sessions (APC 0325) and requested that amount as the minimum 
for a day of PHP (that is, 4 x $66.40=$265.60). Another commenter 
presented two different typical days using proposed CY 2007 rates. 
Typical Day 1 had three Group Therapy sessions (CPT code 90853, APC 
0325, 3 x $66.40) and one Individual Psychotherapy session (CPT code 
90818, APC 0325, $105.68). The commenter priced Typical Day 1 at 
$304.88. Typical Day 2 had one Group Therapy session (CPT code 90853, 
APC 0325, $66.40), one Individual Psychotherapy session (CPT code 
90818, APC 0323, $105.68), and one Family Therapy session (CPT code 
90847, APC 0324, $135.95). The commenter priced Typical Day 2 at 
$308.03. Based on the commenter's presented material, the commenter 
stated that the typical days yield an average componentized rate of 
$306. The commenters questioned how CMS can set rates for APCs 0322 
through 0325, yet are unable to determine a payment rate for a day that 
is comprised of a minimum of three to four of those services. Another 
commenter stated that CMS requires a minimum of four treatments per day 
to qualify for a day of PHP and the proposed per diem rate of $208.27 
for PHP that is less than what CMS would pay for four Group Therapy 
sessions (4 x $66.40=$265.60).
    Response: We do not believe this is an appropriate comparison. The 
commenter does not use the PHP APC, APC 0033. The payment rates for APC 
services cited by the commenter (APC 0323, APC 0324 and APC 0325) are 
not computed from PHP bills. As stated earlier, we used data from PHP 
programs (both hospitals and CMHCs) to determine the median cost of a 
day of PHP. PHP is a program of services where savings can be realized 
by hospitals and CMHCs over delivering individual psychotherapy 
services.
    We structured the PHP APC (0033) as a per diem methodology in which 
the day of care is the unit that reflects the structure and scheduling 
of PHPs and the composition of the PHP APC consists of the cost of all 
services provided each day. Although we require that each PHP day 
include a psychotherapy service, we do not specify the specific mix of 
other services provided and our payment methodology reflects the cost 
per day rather than the cost of each service furnished within the day. 
We note that CMS does not require a minimum of four services.
    Comment: One commenter requested that the same provisions given to 
rural hospital outpatient departments also be given to rural CMHCs.
    Response: We believe the commenter may be referring to the 
statutory hold harmless provisions. Section 1833(t)(7)(D) of the Act 
authorizes such payments, on a permanent basis, for children's 
hospitals and cancer hospitals and, through CY 2005, for rural 
hospitals having 100 or fewer beds and SCHs in rural areas. Section 
1866(t)(7)(D) of the Act does not authorize hold harmless payments to 
CMHC providers. Section 411 of Pub. L. 108-173 required CMS to 
determine the appropriateness of additional payments for certain rural 
hospitals. That authority also does not extend to CMHCs.
    Comment: Representatives of several CMHCs claimed that their costs 
are higher because ``hospitals can share and spread their costs to 
other departments.'' The commenters believed that the CMHC patient 
acuity level is more intense than that for hospital patients because 
hospital outpatient departments need only provide one or two therapies, 
yet still receive the full PHP per diem.
    Response: CMHCs are required to furnish an array of outpatient 
services including specialized outpatient services for children, the 
elderly, individuals with a serious mental illness, and residents of 
its service area who have been discharged from inpatient treatment. 
Accordingly, CMHCs have the same ability to share costs among its 
programs as needed. Further, we believe hospital costs in some areas, 
for example, capital and 24-hour maintenance costs, likely exceed CMHC 
costs.
    Comment: A few commenters stated that hospitals that offer partial 
hospitalization services should not be penalized for the instability in 
data reporting of CMHCs. Another commenter requested that CMS require 
that CMHCs improve their reporting or have that provider group face 
economic consequences.
    Response: We believe that hospital-based programs may have 
benefited from the inclusion of CMHC data, as generally the median 
calculated from hospital outpatient department PHPs was consistently 
far less then the median amount that is computed for CMHCs. We have 
also taken steps to better educate the CMHCs in the cost reporting 
requirements.
    Comment: One commenter asked why there are no CMHCs shown in the 
impact statement. The commenter asked if this is required by 
regulation.
    Response: CMHCs do not share the same characteristics as hospitals 
and do not fit into the traditional impact categories (like bed size). 
Therefore, we have not included them in the impact chart. As PHP is the 
only Medicare service CMHCs provide, the impact is the percentage 
change in the APC amount from year to year. Assuming that the number 
days of PHP provided by CMHCs stays the same as it was in CY 2005, the 
estimated impact on CMHCs as a result of the CY 2007 PHP payment rate 
compared to the CY 2006 PHP payment rate is a 5-percent decrease.
3. Separate Threshold for Outlier Payments to CMHCs
    In the November 7, 2003 final rule with comment period (68 FR 
63469), we indicated that, given the difference in PHP charges between 
hospitals and CMHCs, we did not believe it was appropriate to make 
outlier payments to CMHCs using the outlier percentage target amount 
and threshold established for hospitals. There was a significant 
difference in the amount of outlier payments made to hospitals and 
CMHCs for PHP. In addition, further analysis indicated that using the 
same OPPS outlier threshold for both hospitals and CMHCs did not limit 
outlier payments to high cost cases and resulted in excessive outlier 
payments to CMHCs. Therefore, for CYs 2004, 2005, and 2006, we 
established a separate outlier threshold for CMHCs. For CYs 2004 and 
2005, we designated a portion of the estimated 2.0 percent outlier 
target amount specifically for CMHCs, consistent with the percentage of 
projected payments to CMHCs under the OPPS in each of those years, 
excluding outlier payments. For CY 2006, we set the estimated outlier 
target at 1.0 percent and allocated a portion of that 1.0 percent, 0.6 
percent (or 0.006 percent of total OPPS payments), to CMHCs for PHP 
services. The CY 2006 CMHC outlier threshold is met when the cost of 
furnishing services by a CMHC exceeds 3.40 times the PHP APC payment 
amount. The CY 2006 OPPS outlier payment percentage is 50 percent of 
the amount of costs in excess of the threshold.
    The separate outlier threshold for CMHCs became effective January 
1, 2004, and has resulted in more commensurate outlier payments. In CY 
2004, the separate outlier threshold for

[[Page 68003]]

CMHCs resulted in $1.8 million in outlier payments to CMHCs. In CY 
2005, the separate outlier threshold for CMHCs resulted in $0.5 million 
in outlier payments to CMHCs. In contrast, in CY 2003, more than $30 
million was paid to CMHCs in outlier payments. We believe this 
difference in outlier payments indicates that the separate outlier 
threshold for CMHCs has been successful in keeping outlier payments to 
CMHCs in line with the percentage of OPPS payments made to CMHCs.
    As discussed in section II.B.2. of this preamble, we believe the CY 
2005 CMHC data produce median per diem cost too low to use for the CY 
2007 partial hospitalization payment rate. Due to the continued 
volatility of the CMHC charge data, we proposed to maintain the 
existing outlier threshold for CMHCs for CY 2007 at 3.40 times the APC 
payment amount and the CY 2007 outlier payment percentage applicable to 
costs in excess of the threshold at 50 percent.
    As noted in section II.G. of this preamble, for CY 2007, we 
proposed to continue our policy of setting aside 1.0 percent of the 
aggregate total payments under the OPPS for outlier payments. We 
proposed that a portion of that 1.0 percent, an amount equal to 0.25 
percent of outlier payments and 0.0025 percent of total OPPS payments 
would be allocated to CMHCs for PHP service outliers. As discussed in 
section II.G. of this preamble, we again proposed to set a dollar 
threshold in addition to an APC multiplier threshold for OPPS outlier 
payments. However, because the PHP is the only APC for which CMHCs may 
receive payment under the OPPS, we would not expect to redirect outlier 
payments by imposing a dollar threshold. Therefore, we did not propose 
to set a dollar threshold for CMHC outliers. As noted above, we 
proposed to set the outlier threshold for CMHCs for CY 2007 at 3.40 
percent times the APC payment amount and the CY 2007 outlier payment 
percentage applicable to costs in excess of the threshold at 50 
percent.
    We received no public comments on our proposal. As discussed in 
section II.G. of this preamble, using more recent data for this final 
rule with comment period, we set the target for hospital outpatient 
outlier payments at 1.0 of total OPPS payments. We allocate a portion 
of that 1.0 percent, an amount equal to 0.15 percent of outlier 
payments and 0.0015 percent of total OPPS payments to CMHCs for PHP 
service outliers. For CY 2007, we set the outlier threshold for CMHCs 
for CY 2007 at 3.40 percent times the APC payment amount and the CY 
2007 outlier percentage applicable to costs in excess of the threshold 
at 50 percent.

C. Conversion Factor Update for CY 2007

    Section 1833(t)(3)(C)(ii) of the Act requires us to update the 
conversion factor used to determine payment rates under the OPPS on an 
annual basis. Section 1833(t)(3)(C)(iv) of the Act provides that, for 
CY 2007, the update is equal to the hospital inpatient market basket 
percentage increase applicable to hospital discharges under section 
1886(b)(3)(B)(iii) of the Act.
    The hospital market basket increase for FY 2007 published in the 
IPPS final rule on August 18, 2006 is 3.4 percent (71 FR 48146), the 
same as the forecast published in the FY 2007 IPPS proposed rule on 
April 25, 2006 (71 FR 24148). To set the OPPS proposed conversion 
factor for CY 2007, we increased the CY 2006 conversion factor of 
$59.511, as specified in the November 10, 2005 final rule with comment 
period (70 FR 68551), by 3.4 percent.
    In accordance with section 1833(t)(9)(B) of the Act, we further 
adjusted the conversion factor for CY 2006 to ensure that the revisions 
we are making to our updates for a revised wage index and expanded 
rural adjustment are made on a budget neutral basis. We calculated a 
budget neutrality factor of 0.999331979 for wage index changes by 
comparing total payments from our simulation model using the FY 2007 
IPPS final wage index values as finalized to those payments using the 
current (FY 2006) IPPS wage index values. To reflect the inclusion of 
essential access community hospitals (EACHs) as rural SCHs (discussed 
in section II.F. of this preamble), we calculated an additional budget 
neutrality factor of 0.999975941 for the rural adjustment, including 
EACHs. For CY 2007, we estimate that allowed pass-through spending 
would equal approximately $65.6 million, which represents 0.21 percent 
of total OPPS projected spending for CY 2007. The final conversion 
factor also is adjusted by the difference between the 0.17 percent 
pass-through dollars set-aside in CY 2006 and the 0.21 percent estimate 
for CY 2007 pass-through spending. Finally, payments for outliers 
remain at 1.0 percent of total payments for CY 2007.
    The market basket increase update factor of 3.4 percent for CY 
2007, the required wage index budget neutrality adjustment of 
approximately 0.999331979, the adjustment of 0.04 percent for the 
difference in the pass-through set-aside, and the adjustment for the 
rural payment adjustment for rural SCHs, including rural EACHs, of 
0.999975941 result in a standard conversion factor for CY 2007 of 
$61.468.
    We received many public comments on the calculation of the proposed 
conversion factor updates for CY 2007 with regard to the proposal to 
reduce the CY 2007 conversion factor for failure to report the IPPS 
RHQDAPU data. These comments are addressed in section XIX. of this 
preamble. We received no other comments on the proposed conversion 
factor update for CY 2007.

D. Wage Index Changes for CY 2007

    Section 1833(t)(2)(D) of the Act requires the Secretary to 
determine a wage adjustment factor to adjust, for geographic wage 
differences, the portion of the OPPS payment rate and the copayment 
standardized amount attributable to labor and labor-related cost. Since 
the inception of the OPPS, CMS policy has been to wage adjust 60 
percent of the OPPS payment, based on a regression analysis that 
determined that approximately 60 percent of the costs of services paid 
under OPPS were attributable to wage costs. We did not propose to 
revise this policy for CY 2007 OPPS. See section II.H. of this final 
rule with comment period for a description and example of how the wage 
index for a particular hospital is used to determine the payment for 
the hospital.
    This adjustment must be made in a budget neutral manner. As we have 
done in prior years, we proposed to adopt the IPPS wage indices and 
extend these wage indices to hospitals that participate in the OPPS but 
not the IPPS (referred to in this section as ``non-IPPS'' hospitals).
    As discussed in section II.A. of this preamble, we standardize 60 
percent of estimated costs (labor-related costs) for geographic area 
wage variation using the IPPS wage indices that are calculated prior to 
adjustments for reclassification to remove the effects of differences 
in area wage levels in determining the OPPS payment rate and the 
copayment standardized amount.
    As published in the original OPPS April 7, 2000 final rule with 
comment period (65 FR 18545), OPPS has consistently adopted the final 
IPPS wage indices as the wage indices for adjusting the OPPS standard 
payment amounts for labor market differences. Thus, the wage index that 
applies to a particular hospital under the IPPS will also apply to that 
hospital under the OPPS. As initially explained in the September 8, 
1998 OPPS proposed rule, we believed and continue to believe that

[[Page 68004]]

using the IPPS wage index as the source of an adjustment factor for 
OPPS is reasonable and logical, given the inseparable, subordinate 
status of the hospital outpatient within the hospital overall. In 
accordance with section 1886(d)(3)(E) of the Act, the IPPS wage index 
is updated annually. In the CY 2007 OPPS proposed rule, in accordance 
with our established policy, we proposed to use the FY 2007 final 
version of these wage indices to determine the wage adjustments for the 
OPPS payment rate and copayment standardized amount that would be 
published in our final rule with comment period for CY 2007 which will 
include the finalized wage indices in effect through March 31, 2007, 
and those in effect on or after April 1, 2007, to accommodate the 
expiring reclassification provisions under section 508 of Pub. L. 108-
173 to determine the wage adjustments for the OPPS payment rate and 
copayment standardized amount.
    On May 17, 2006 (71 FR 28644), in response to a court order in 
Bellevue Hosp. Ctr. v. Leavitt, we published a second IPPS proposed 
rule that would revise the methodology for calculating the occupational 
mix adjustment for FY 2007. We proposed to replace in full the 
descriptions of the data and methodology that would be used in 
calculating the occupational mix adjustment discussed in the first FY 
2007 IPPS proposed rule. The second proposed rule also states that, 
because of the collection of new occupational mix data, we would 
publish the FY 2007 occupational mix adjusted wage index tables and 
related impacts on the CMS Web site shortly after we published the FY 
2007 IPPS final rule, and in advance of October 1, 2006. The weights 
and factors would also be published on the CMS Web site after the FY 
2007 IPPS final rule, but in advance of October 1, 2006 (71 FR 28650). 
On October 11, 2006 (71 FR 59886), we published an IPPS notice in the 
Federal Register that, in part, finalized the adjusted occupational mix 
wage indices published in the FY 2007 IPPS final rule. Readers are 
directed to refer to the wage index tables that were published on the 
CMS Web site before October 1, 2006.
    We note that the FY 2007 IPPS wage indices continue to reflect a 
number of changes implemented in FY 2005 as a result of the revised 
Office of Management and Budget (OMB) standards for defining geographic 
statistical areas, the implementation of an occupational mix adjustment 
as part of the wage index, and new wage adjustments provided for under 
Pub. L. 108-173. The following is a brief summary of the changes in the 
FY 2005 IPPS wage indices, continued for FY 2007, and any adjustments 
that we are applying to the OPPS for CY 2007. We refer the reader to 
the FY 2007 IPPS final rule (71 FR 48005 through 48028) for a detailed 
discussion of the changes to the wage indices. Readers should refer 
also to our IPPS notice published in the Federal Register on October 
11, 2006, for finalized changes to the adjusted occupational mix wage 
indices and related issues (71 FR 59886). In this final rule with 
comment period, we are not reprinting the FY 2007 IPPS wage indices 
referenced in the discussion below, with the exception of the out-
migration wage adjustment table (Addendum L of this final rule with 
comment period). We also refer readers to the CMS Web site for the OPPS 
at http://www.cms.hhs.gov/providers/hopps. At this Web site, the reader 
will find a link to the finalized FY 2007 IPPS wage indices tables.
    1. The continued use of the Core Based Statistical Areas (CBSAs) 
issued by the OMB as revised standards for designating geographical 
statistical areas based on the 2000 Census data, to define labor market 
areas for hospitals for purposes of the IPPS wage index. The OMB 
revised standards were published in the Federal Register on December 
27, 2000 (65 FR 82235), and OMB announced the new CBSAs on June 6, 
2003, through an OMB bulletin. In the FY 2005 IPPS final rule, CMS 
adopted the new OMB definitions for wage index purposes. In the FY 2007 
IPPS final rule, we again stated that hospitals located in MSAs will be 
urban and hospitals that are located in Micropolitan Areas or outside 
CBSAs will be rural. To help alleviate the decreased payments for 
previously urban hospitals that became rural under the new geographical 
definitions, we allowed these hospitals to maintain for the 3-year 
period from FY 2005 through FY 2007, the wage index of the MSA where 
they previously had been located. To be consistent with the IPPS, we 
will continue the policy we began in CY 2005 of applying the same 
urban-to-rural transition to non-IPPS hospitals paid under the OPPS. 
That is, we would maintain the wage index of the MSA where the hospital 
was previously located for purposes of determining a wage index for CY 
2007. Beginning in FY 2008, the 3-year transition will end and these 
hospitals will receive their statewide rural wage index. However, 
hospitals paid under the IPPS will be eligible to apply for 
reclassification.
    For the occupational mix adjustment, we refer readers to the FY 
2007 IPPS final rule and the October 11, 2006 IPPS notice discussed 
above. Under that final rule, the wage indices are adjusted 100 percent 
for occupational mix. In addition, as stated above, the finalized 
version of the FY 2007 IPPS wage index tables and other adjustment 
factors were published in the October 11, 2006 IPPS notice and are 
applicable to discharges occurring on or after October 1, 2006.
    As noted above, for purposes of estimating an adjustment for the 
OPPS payment rates to accommodate geographic differences in labor costs 
in this final rule with comment period, we have used the finalized FY 
2007 IPPS wage indices identified in the October 11, 2006 IPPS notice 
that are fully adjusted for differences in occupational mix using the 
new survey data, effective October 1, 2006. As proposed, in all cases, 
we are using the finalized FY 2007 IPPS wage indices, which include the 
wage indices to be in effect through March 31, 2007, and those to be in 
effect on or after April 1, 2007, with any subsequent corrections, for 
calculating OPPS payment in CY 2007.
    2. The reclassifications of hospitals to geographic areas for 
purposes of the wage index. For purposes of the OPPS wage index, we 
proposed to adopt all of the IPPS reclassifications for FY 2007, 
including reclassifications that the Medicare Geographic Classification 
Review Board (MGCRB) approved under the one-time appeal process for 
hospitals under section 508 of Pub. L. 108-173. We note that section 
508 reclassifications will terminate March 31, 2007, and that this 
expiration, along with the calendar year operating period of OPPS, 
impacts the calculation of the OPPS payment and the budget neutrality 
adjustment for the wage index. In the FY 2007 IPPS final rule (71 FR 
48024 and 48025), we finalized the procedural rules for hospitals that 
wished to reclassify for the second half of FY 2007 (April 1, 2007, 
through September 30, 2007) under section 1886(d)(10) of the Act. These 
rules essentially provided procedures for some hospitals to retain 
section 508 reclassifications for the first half of FY 2007 and also be 
eligible to maintain an approved reclassification under section 
1886(d)(10) for the second half of FY 2007. Rather than calculating one 
wage index that reflected all final reclassification adjustments, we 
will calculate two separate wage indices for FY 2007, one to be in 
effect October 1 through March 31, 2007, and one to be in effect April 
1 through September 30, 2007.
    These procedural rules also impact a hospital's eligibility to 
receive the out-migration wage adjustment, discussed

[[Page 68005]]

in greater detail in section III.I. of the FY 2007 IPPS final rule (71 
FR 48026) and under section II.D.4. of this preamble. A hospital cannot 
receive an out-migration wage adjustment if it is reclassified under 
section 1886(d)(10) of the Act. Hospitals declining reclassification 
status for any part of the year become eligible to receive the out-
migration wage adjustment if they are located in an adjustment county. 
We note that because the OPPS operates on a calendar year (January 1 
through December 31) and not a fiscal year, the expiring 
reclassification status under section 508 of Pub. L. 108-173 results in 
different wage indices for OPPS for the first quarter of CY 2007 
(January 1, 2007, through March 31, 2007) and the last three quarters 
of CY 2007 (April 1, 2007, through December 31, 2007).
    3. The out-migration wage adjustment to the wage index. In FY 2007 
IPPS final rule (71 FR 48026), we discussed the out-migration 
adjustment under section 505 of Pub. L. 109-173 for counties under this 
adjustment. Hospitals paid under the IPPS located in the qualifying 
section 505 ``out-migration'' counties receive a wage index increase 
unless they have already been otherwise reclassified. (See the IPPS FY 
2007 final rule for further information on out-migration.) For OPPS 
purposes, we proposed to continue our policy from CY 2006 to allow non-
IPPS hospitals paid under the OPPS to qualify for out-migration 
adjustment if they are located in a section 505 out-migration county. 
Because non-IPPS hospitals cannot reclassify, they are eligible for the 
out-migration wage adjustment. Tables identifying counties eligible for 
the out-migration adjustment were published after the FY 2007 IPPS 
final rule on October 11, 2006 (71 FR 59886). These tables reflect 
updated county listing to reflect changes to the occupation mix 
adjustment made in response to Bellevue court case discussed above. 
Because we proposed to adopt the final FY 2007 IPPS wage index, we are 
adopting any changes in a hospital's classification status that will 
make them either eligible or ineligible for the out-migration wage 
adjustment both through March 31, 2007, and on or after April 1, 2007.
    With the exception of reclassifications resulting from the 
implementation of the one-time appeal process under section 508 of Pub. 
L. 108-173, all changes to the wage index resulting from geographic 
labor market area reclassifications or other adjustments must be 
incorporated in a budget neutral manner. Accordingly, in calculating 
the OPPS budget neutrality estimates for CY 2007, in this final rule 
with comment period, we have included the wage index changes that would 
result from MGCRB reclassifications, implementation of section 505 of 
Pub. L. 108-173, and other refinements made in the FY 2007 IPPS final 
rule, such as the hold harmless provision for hospitals changing status 
from urban to rural under the new CBSA geographic statistical area 
definitions. However, section 508 sets aside $900 million to implement 
the section 508 reclassifications. We considered the increased Medicare 
payments that the section 508 reclassifications would create in both 
the IPPS and OPPS when we determined the impact of the one-time appeal 
process. Because the increased OPPS payments already count against the 
$900 million limit, we did not consider these reclassifications when we 
calculated the OPPS budget neutrality adjustment.
    Under the procedural rules described under section II.D.3. of this 
final rule with comment period and in section III.H.6. of the FY 2007 
IPPS final rule (71 FR 48024) regarding expiring section 508 
reclassifications, different wage indices may be in effect for the 
first quarter of the calendar year and the last three quarters of the 
calendar year. These rules have implications for budget neutrality 
adjustments. Any additional payment attributable to reclassifications 
due to section 508 between January 1 and April 1, 2007, must be 
excluded from a budget neutrality adjustment, and all other adjustments 
to the wage index are subject to budget neutrality. Rather than 
calculating two different conversion factors, with different budget 
neutrality adjustments, we proposed to calculate one budget neutrality 
adjustment that reflects the combined adjustments required for the 
first quarter and last three quarters of the calendar year, 
respectively. We followed the same approach in the FY 2007 IPPS final 
rule (71 FR 48026).
    We received several comments on the proposed wage index policy for 
the CY 2007 OPPS.
    Comment: One commenter urged CMS to use the IPPS labor-related 
adjustment to determine reimbursements for outpatient services. 
Specifically, the commenter requested that the labor-related percentage 
for the OPPS be revised from the 60 percent currently proposed to 69.7 
percent, consistent with what is stated in the FY 2007 IPPS rule. The 
commenter further requested that, at a minimum, CMS update the OPPS 
labor-related share in effect for CY 2007 from 60 percent to 63 
percent, the labor-related percentage referenced by CMS in the CY 2006 
OPPS final rule.
    Response: We did not propose a change to the labor share, but we do 
not believe that such a change is appropriate. The determination to 
wage adjust 60 percent of the payment of each APC was made based on a 
regression analysis at the beginning of the OPPS. We repeated this 
analysis as part of the rural adjustment study we performed for the CY 
2006 OPPS based on CY 2004 claims data. This study examined the extent 
to which the body of costs for services furnished in the outpatient 
department was split between wage and nonwage costs and, based on our 
most recent findings, we believe that it remains appropriate to wage 
adjust 60 percent of the APC payment (70 FR 68533).
    Comment: One commenter urged CMS to postpone the implementation of 
100 percent of the occupational mix survey adjustment until the DRG 
severity refinements can be fully implemented and their possible 
unrecognized adverse effects on quality of care and outcomes can be 
resolved. Another commenter expressed concern about the application of 
the 100-percent occupational mix adjustment for CY 2007. The commenter 
encouraged CMS to approach Congress for authority to transition the 
occupational mix and to repeal the mandate that CMS apply an 
occupational mix adjustment to wage indices.
    Response: We appreciate the comments concerning this issue and 
refer readers to the CMS final rule for the CY 2007 IPPS ( 71 FR 48006) 
for a discussion of the reasons that CMS adopted a 100 percent 
occupational mix adjusted wage index for hospitals receiving payments 
under the IPPS. As first published in the original OPPS final rule on 
April 7, 2000 (65 FR 18545), the OPPS has consistently adopted the 
final IPPS wage indices as the wage indices for adjusting the OPPS 
standard payment amounts for labor market differences. We continue to 
believe that using the IPPS wage index as the source of an adjustment 
factor for the OPPS is reasonable and logical given the inseparable, 
subordinate status of the hospital outpatient department within the 
hospital overall. Therefore, given that a 100 percent occupational mix 
adjusted wage index was adopted in the IPPS, we will also adopt the 
same index for the OPPS.
    After carefully considering all public comments received, we are 
finalizing our wage index adjustment policy for the CY 2007 OPPS as 
proposed without modification.

[[Page 68006]]

E. Statewide Average Default CCRs

    CMS uses CCRs to determine outlier payments, payments for pass-
through devices, and monthly interim transitional corridor payments 
under the OPPS. Some hospitals do not have a valid CCR. These hospitals 
include, but are not limited to, hospitals that are new and have not 
yet submitted a cost report, hospitals that have a CCR that falls 
outside predetermined floor and ceiling thresholds for a valid CCR, or 
hospitals that have recently given up their all-inclusive rate status. 
Last year, we updated the default urban and rural CCRs for CY 2006 in 
our final rule with comment period published on November 10, 2005 (70 
FR 68553 through 68555). As we proposed, in this final rule with 
comment period, we have updated the default ratios for CY 2007 using 
the most recent cost report data.
    We calculated the statewide default CCRs using the same overall 
CCRs that we use to adjust charges to costs on claims data. Refer to 
section II.A.1.c. of this preamble for a discussion of our revision to 
the overall CCR calculation. Table 4 published in the CY 2007 OPPS 
proposed rule listed the proposed CY 2007 default urban and rural CCRs 
by State and compared them to last year's default CCRs (71 FR 49542 
through 49545). These CCRs are the ratio of total costs to total 
charges from each provider's most recently submitted cost report, for 
those cost centers relevant to outpatient services weighted by Medicare 
Part B charges. We also adjusted these ratios to reflect final settled 
status by applying the differential between settled to submitted costs 
and charges from the most recent pair of settled to submitted cost 
reports.
    For the proposed rule, 81.79 percent of the submitted cost reports 
represented data for CY 2004. We have since updated the cost report 
data we use to calculate CCRs with additional submitted cost reports 
for CY 2005. For this final rule with comment period, 66.41 percent of 
the submitted cost reports utilized in the default ratio calculation 
were for CY 2004, whereas 34.95 percent were for CY 2005. We only used 
valid CCRs to calculate these default ratios. That is, we removed the 
CCRs for all-inclusive hospitals, CAHs, and hospitals in Guam and the 
U.S. Virgin Islands because these entities are not paid under the OPPS, 
or in the case of all-inclusive hospitals, because their CCRs are 
suspect. We further identified and removed any obvious error CCRs and 
trimmed any outliers. We limited the hospitals used in the calculation 
of the default CCRs to those hospitals that billed for services under 
the OPPS during CY 2004.
    Finally, we calculated an overall average CCR, weighted by a 
measure of volume for CY 2004, for each State except Maryland. This 
measure of volume is the total lines on claims and is the same one that 
we use in our impact tables. For Maryland, we used an overall weighted 
average CCR for all hospitals in the Nation as a substitute for 
Maryland CCRs. Very few providers in Maryland are eligible to receive 
payment under the OPPS, which limits the data available to calculate an 
accurate and representative CCR. The observed differences between last 
year's default statewide CCRs and the CY 2007 CCRs are a combination of 
the general decline in the ratio between costs and charges widely 
observed in the cost report data and the change in the proposed overall 
CCR calculation.
    As stated above, CMS uses default statewide CCRs for several groups 
of hospitals, including, but not limited to, hospitals that are new and 
have not yet submitted a cost report, hospitals that have a CCR that 
falls outside predetermined floor and ceiling thresholds for a valid 
CCR, and hospitals that have recently given up their all-inclusive rate 
status. Current OPPS policy also requires hospitals that experience a 
change of ownership, but that do not accept assignment of the previous 
hospital's provider agreement, to use the previous provider's CCR.
    For CY 2007, we proposed to apply this treatment of using the 
default statewide CCR to include an entity that has not accepted 
assignment of an existing hospital's provider agreement in accordance 
with Sec.  489.18, and that has not yet submitted its first Medicare 
cost report. We proposed that this policy be effective for hospitals 
experiencing a change of ownership on or after January 1, 2007. We 
believed that a hospital that has not accepted assignment of an 
existing hospital's provider agreement is similar to a new hospital 
that will establish its own costs and charges. We believed that the 
hospital that has chosen not to accept assignment may have different 
costs and charges than the existing hospital. Furthermore, we believed 
that the hospital should be provided time to establish its own costs 
and charges. Therefore, we proposed to use the default statewide CCR to 
determine cost-based payments until the hospital has submitted its 
first Medicare cost report.
    We did not receive any public comments concerning the proposed 
statewide average default CCR. Therefore, we are finalizing the 
statewide average default CCRs shown in Table 4 below for OPPS services 
furnished on or after January 1, 2007 without modification.
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F. OPPS Payments to Certain Rural Hospitals

1. Hold Harmless Transitional Payment Changes Made by Pub. L. 109-171 
(DRA)
    When the OPPS was implemented, every provider was eligible to 
receive an additional payment adjustment (transitional corridor 
payment) if the payments it received for covered OPD services under the 
OPPS were less than the payments it would have received for the same 
services under the prior reasonable cost-based system. Section 
1833(t)(7) of the Act provides that the transitional corridor payments 
are temporary payments for most providers, with two exceptions, to ease 
their transition from the prior reasonable cost-based payment system to 
the OPPS system. Cancer hospitals and children's hospitals receive the 
transitional corridor payments on a permanent basis. Section 
1833(t)(7)(D)(i) of the Act originally provided for transitional 
corridor payments to rural hospitals with 100 or fewer beds for covered 
OPD services furnished before January 1, 2004. However, section 411 of 
Pub. L. 108-173 amended section 1833(t)(7)(D)(i) of the Act to extend 
these payments through December 31, 2005, for rural hospitals with 100 
or fewer beds. Section 411 also extended the transitional corridor 
payments to sole community hospitals (SCHs) located in rural areas for 
services furnished during the period that begins with the provider's 
first cost reporting period beginning on or after January 1, 2004, and 
ends on December 31, 2005. Accordingly, the authority for making 
transitional corridor payments under section 1833(t)(7)(D)(i) of the 
Act, as amended by section 411 of Pub. L. 108-173, expired for rural 
hospitals having 100 or fewer beds and SCHs located in rural areas on 
December 31, 2005.
    Section 5105 of Pub. L. 109-171 reinstituted the hold harmless 
transitional outpatient payments (TOPs) for covered OPD services 
furnished on or after January 1, 2006, and before January 1, 2009, for 
rural hospitals having 100 or fewer beds that are not SCHs. When the 
OPPS payment is less than the payment the provider would have received 
under the previous reasonable cost-based system, the amount of payment 
is increased by 95 percent of the amount of the difference

[[Page 68010]]

between those two payment systems for CY 2006, by 90 percent of the 
amount of that difference for CY 2007, and by 85 percent of the amount 
of that difference for CY 2008.
    For CY 2006, we have implemented section 5105 of Pub. L. 109-171 
through Transmittal 877, issued on February 24, 2006. We did not 
specifically address whether TOPs payments apply to essential access 
community hospitals (EACHs), which are considered to be SCHs under 
section 1886(d)(5)(D)(iii)(III) of the Act. Accordingly, under the 
statute, EACHs are treated as SCHs. Therefore, we believe that EACHs 
are not eligible for TOPs payment under Pub. L. 109-171. In the CY 2007 
OPPS proposed rule, we proposed to update Sec.  419.70(d) to reflect 
the requirements of Pub. L. 109-171.
2. Adjustment for Rural SCHs Implemented in CY 2006 Related to Pub. L. 
108-173 (MMA)
    In the CY 2006 OPPS final rule with comment period (70 FR 68556), 
we finalized a payment increase for rural SCHs of 7.1 percent for all 
services and procedures paid under the OPPS, excluding drugs, 
biologicals, brachytherapy seeds, and services paid under pass-through 
payment policy in accordance with section 1833(t)(13)(B) of the Act, as 
added by section 411 of Pub. L. 108-173. Section 411 gave the Secretary 
the authority to make an adjustment to OPPS payments for rural 
hospitals, effective January 1, 2006, if justified by a study of the 
difference in costs by APC between hospitals in rural and urban areas. 
Our analysis showed a difference in costs only for rural SCHs and we 
implemented a payment adjustment for those hospitals beginning January 
1, 2006.
    As indicated in the CY 2007 OPPS proposed rule (71 FR 49547), we 
recently became aware that we did not specifically address whether the 
adjustment applies to EACHs, which are considered to be SCHs under 
section 1886(d)(5)(D)(iii)(III) of the Act. Thus, under the statute, 
EACHs are treated as SCHs. Currently, fewer than 10 hospitals are 
classified as EACHs. As of CY 1998, under section 4201(c) of Pub. L. 
105-33, a hospital can no longer become newly classified as an EACH. 
Therefore, for purposes of receiving this rural adjustment, we are 
clarifying that EACHs are treated as SCHs for purposes of receiving 
this adjustment, assuming these entities otherwise meet the rural 
adjustment criteria.
    This adjustment is budget neutral and applied before calculating 
outliers and coinsurance. We also stated that we would not reestablish 
the adjustment amount on an annual basis, but that we might review the 
adjustment in the future and, if appropriate, would revise the 
adjustment. For CY 2007, we proposed to continue our current policy of 
a budget neutral 7.1 percent payment increase for rural SCHs for 
specified services.
    Comment: Many commenters expressed concern that small rural 
hospitals will suffer financially if TOPs payments continue to decrease 
each year, as specified in section 5105 of Pub. L. 109-171. The 
commenters noted that patient access to small rural hospitals could be 
at risk. One commenter supported permanent TOPs for rural SCHs, which 
currently do not receive any TOPs payments. Several commenters noted 
their support for a Senate bill, S.3606, which is known as the ``Save 
our Safety Net Act of 2005.''
    Response: We share the concerns of rural hospitals and do not 
intend to limit access to health care for Medicare beneficiaries in 
rural areas. However, we note that the statute is very specific and 
does not provide TOPs payments for entities other than those listed in 
the statute. The statute also requires TOPs payments to gradually 
decrease through CY 2008.
    Comment: Several commenters requested that CMS clarify that the 7.1 
percent rural SCH adjustment applies to EACHs retroactive to January 1, 
2006.
    Response: As stated above, we are clarifying that EACHs are treated 
as SCHs for purposes of receiving this adjustment, assuming these 
entities otherwise meet the rural adjustment criteria. EACHs are 
eligible for this adjustment effective January 1, 2006, as are all 
rural SCHs. As stated above, we agree with the commenters and are 
revising Sec.  419.43(g) to specifically reflect this clarification. In 
addition, we will ensure that a retroactive payment adjustment occurs.
    Comment: Several commenters supported the 7.1 percent adjustment 
for rural SCHs for CY 2007, but requested that CMS rerun the analyses 
to possibly provide for an adjustment for other rural hospitals during 
CY 2008 and CY 2009, when TOPs payments will be further reduced.
    Response: As stated above, while we will not reestablish the 
adjustment amount nor determine whether other rural hospitals are 
eligible for the adjustment on an annual basis, we may review the 
adjustment in the future and, if appropriate, would revise the 
adjustment.
    After carefully considering the comments received, we are 
finalizing our policy by continuing a payment adjustment for rural 
SCHs, including EACHs, of 7.1 percent and finalizing the regulation 
text at Sec.  419.70(d) without modification. We are also revising 
Sec.  419.43(g) to clarify that EACHs are also eligible for the rural 
SCH OPPS adjustment.

G. CY 2007 Hospital Outpatient Outlier Payments

    Currently, the OPPS pays outlier payments on a service-by-service 
basis. For CY 2006, the outlier threshold is met when the cost of 
furnishing a service or procedure by a hospital exceeds 1.75 times the 
APC payment amount and exceeds the APC payment rate plus a $1,250 
fixed-dollar threshold. We introduced a fixed-dollar threshold in CY 
2005 in addition to the traditional multiple threshold in order to 
better target outliers to those high cost and complex procedures where 
a very costly service could present a hospital with significant 
financial loss. If a provider meets both of these conditions, the 
multiple threshold and the fixed-dollar threshold, the outlier payment 
is calculated as 50 percent of the amount by which the cost of 
furnishing the service exceeds 1.75 times the APC payment rate. For a 
discussion on CMHC outliers, see section II.B.3. of the preamble to 
this final rule with comment period.
    As explained in the CY 2006 OPPS final rule with comment period (70 
FR 68561), we set our projected target for aggregate outlier payments 
at 1.0 percent of aggregate total payments under the OPPS. The outlier 
thresholds were set so that estimated CY 2006 aggregate outlier 
payments would equal 1.0 percent of aggregate total payments under the 
OPPS. In the CY 2006 OPPS final rule with comment period (70 FR 68563), 
we also published total outlier payments as a percent of total 
expenditures for past years. However, when we published the CY 2007 
OPPS proposed rule, we did not have a complete set of CY 2005 claims 
data to produce this number for CY 2005 and stated that we would report 
on CY 2005 outlier payments in this CY 2007 OPPS final rule with 
comment period. In the final set of CY 2005 OPPS claims, aggregated 
outlier payments were 2.39 percent of aggregated total OPPS payments. 
For CY 2005, the estimated outlier payments were set at 2 percent of 
the total aggregated OPPS payments. Therefore, for CY 2005, we paid 
0.39 percent in excess of the CY 2005 outlier target of 2 percent of 
total aggregated OPPS payments.
1. CY 2007 Proposal
    For CY 2007, we proposed to continue our policy of setting aside 
1.0 percent of

[[Page 68011]]

aggregate total payments under the OPPS for outlier payments. We 
proposed that a portion of that 1.0 percent would be allocated to CMHCs 
for partial hospitalization program service outliers. We proposed that 
the portion allocated to CMHCs would be determined by the amount of 
estimated outlier payments resulting from the CMHC outlier threshold.
    In order to ensure that estimated CY 2007 aggregate outlier 
payments would equal 1.0 percent of estimated aggregate total payments 
under the OPPS, we proposed that the outlier threshold be set so that 
outlier payments would be triggered when the cost of furnishing a 
service or procedure by a hospital exceeds 1.75 times the APC payment 
amount and exceeds the APC payment rate plus a $1,825 fixed-dollar 
threshold.
    We calculated the fixed-dollar threshold for the CY 2007 proposed 
rule using the same methodology as we did in CY 2006, except we used 
the revised overall CCR calculation discussed in section II.A.1.c. of 
this preamble. As discussed in section II.A.1.c. of this preamble, we 
discovered that the calculation of the overall CCR that the fiscal 
intermediaries are using to determine outlier payment and payment for 
services paid at charges reduced to cost differs from the overall CCR 
that we traditionally use to model the outlier thresholds. We 
discovered this during our calculations of the outlier threshold for 
the CY 2006 OPPS final rule with comment period, and we indicated in 
our preamble discussion for that rule, that we might revisit the 
threshold estimate methodology in light of identified differences in 
the overall CCR calculation. Because, on average, the overall CCR 
calculation used by the fiscal intermediaries results in higher CCRs 
than those estimated using our ``traditional'' CCR sets, the outlier 
threshold calculated for the CY 2006 OPPS final rule with comment 
period is too low. The OPPS impact table in section XXVII. of the CY 
2007 proposed rule (Table 49; 71 FR 49687) demonstrated an estimated 
payment differential of 0.25 percent of total spending for hospital 
outlier payments in CY 2006 because of the differences in overall CCR 
calculations. The revised overall CCR calculation that we proposed for 
CY 2007 aligns the two CCR calculations by removing allied and nursing 
health costs for those hospitals with paramedical education programs 
from the fiscal intermediary's CCR calculation and weighting our 
``traditional'' calculation by total Medicare Part B charges. We 
expected this proposed change in the overall CCR calculation to raise 
the outlier threshold.
2. CY 2007 Final Rule Outlier Calculation
    The claims that we use to model each OPPS update lag by 2 years. 
For this final rule with comment period, we used CY 2005 claims to 
model the CY 2007 OPPS. In order to estimate CY 2007 outlier payments 
for this final rule with comment period, we inflated the charges on the 
CY 2005 claims using the same inflation factor of 1.1642 that we used 
to estimate the IPPS fixed-dollar outlier threshold for the FY 2007 
IPPS final rule. For 1 year, the inflation factor is 1.079. The 
methodology for determining this charge inflation factor was discussed 
in the FY 2007 IPPS final rule (71 FR 48150). As we stated in the CY 
2005 OPPS final rule with comment period, we believe that the use of 
this charge inflation factor is appropriate for the OPPS because, with 
the exception of the routine service cost centers, hospitals use the 
same cost centers to capture costs and charges across inpatient and 
outpatient services (69 FR 65845). As also noted in the FY 2006 IPPS 
final rule, we believe that a charge inflation factor is more 
appropriate than an adjustment to costs because this methodology 
closely captures how actual outlier payments are made and calculated 
(70 FR 47495). We then applied the revised overall CCR that we 
calculated from each hospital's most recent cost report (CMS-2552-96) 
and, if the cost report was not settled, we adjusted it by a settled-
to-submitted ratio. We simulated aggregated outlier payments using 
these costs for several different fixed-dollar thresholds holding the 
1.75 multiple constant until the total outlier payments equaled 1.0 
percent of aggregated total OPPS payments. We estimate that a threshold 
of $1,825 combined with the multiple threshold of 1.75 times the APC 
payment rate would allocate 1.0 percent of aggregated total OPPS 
payments to outlier payments.
    For CMHCs, in CY 2007 we are projecting that the outlier threshold 
is met when the cost of furnishing a service or procedure by a CMHC 
exceeds 3.40 times the APC payment rate. If a CMHC provider meets this 
condition, the outlier payment is calculated as 50 percent of the 
amount by which the cost exceeds 3.40 times the APC payment rate. In 
the CY 2007 OPPS proposed rule, we proposed to continue the same 
threshold policy for CY 2007 as we have established for CY 2006. An 
explanation for this proposed policy is discussed in section II.B.3. of 
the preamble to this final rule with comment period.
    We received many comments on our proposed outlier policy for CY 
2007.
    Comment: Some commenters were concerned that the outlier threshold 
that CMS proposed is set too high and will result in CMS not spending 
all of the money in the projected 1.0 percent outlier target. The 
commenters stated that the estimated outlier target amount has 
historically been greater than the actual need, and they asked that CMS 
either reduce the set aside amount and retain that money in the OPPS 
rates or reduce the threshold for qualification so that the outlier 
expenditures are at a zero balance at the end of each year. One 
commenter asked that CMS limit the increase in the outlier threshold to 
the amount of the market basket update each year, which would mean, for 
CY 2007, that the CY 2006 threshold would be increased by only 3.4 
percent.
    Response: We believe that the threshold of $1,825 will result in 
paying 1.0 percent of the OPPS expenditures in outliers. As we 
indicated in the CY 2006 OPPS final rule, in the final set of CY 2004 
OPPS claims, aggregated outlier payments were 2.5 percent of aggregated 
total OPPS payments. Similarly, using the final set of CY 2003 OPPS 
claims, aggregated outlier payments were 3.1 percent of total OPPS 
payments. As stated earlier, in the final set of CY 2005 claims, 
aggregated outlier payments were 2.39 percent of the aggregated total 
OPPS payments. For all three years, the estimated outlier payments were 
set at 2.0 percent of the total aggregated OPPS payments. Hence, our 
historic estimation of outlier payments has resulted in outlier 
payments that exceeded our target, and we believe that our proposed 
methodology will provide an outlier threshold that will result in more 
accurate aggregate program outlier payments.
    As discussed above, for the proposed rule, we used a charge 
inflation factor of 1.1515 to inflate the charges for CY 2005 claims to 
CY 2007 dollars. We then applied the provider's overall CCR that we 
calculate as part of our APC median estimation process to those 
inflated charges to estimate costs. We compared these estimated costs 
to 1.75 times the proposed APC payment amount and to the APC payment 
amount plus a number of fixed-dollar thresholds until we identified a 
threshold that produced an estimate of total outlier payments equal to 
1.0 percent of total aggregated OPPS payments.
    We used the same estimation process for this final rule with 
comment period. We used a complete set of CY 2005 claims, and the 
updated charge inflation

[[Page 68012]]

estimate of 1.1642 percent from the FY 2007 IPPS final rule and each 
hospital's overall CCR, as calculated for our APC median setting 
process.
    Using this methodology, the final fixed-dollar threshold for the CY 
2007 OPPS is $1,825, and the final multiple threshold is 1.75 times the 
APC payment rate.
    We did not increase the CY 2007 outlier threshold by the market 
basket update of 3.4 percent because our calculations are intended to 
best approximate the outlier target of 1.0 percent of CY 2007 OPPS 
expenditures. As we stated in the CY 2006 OPPS final rule, we 
established the projected target for aggregate outlier payments at 1.0 
percent because we believed, consistent with MedPAC's recommendations, 
that the fairly narrow definitions of APC groups make outlier payment 
less necessary for the OPPS, that multiple service payments are common 
for any given claim, and that the susceptibility to ``gaming'' through 
charge inflation continues (70 FR 68563). Because OPPS outlier payments 
are targeted to services, rather than clinical cases, we believe it is 
unlikely that any specific service would be excessively costly, and 
reducing the outlier threshold to 1.0 percent of total OPPS payment 
effectively raises the payment for all other services. We continue to 
believe that an outlier target of 1.0 percent of total OPPS payment is 
appropriate for the OPPS.
    Comment: One commenter asked that CMS modify the charge methodology 
used to set the OPPS outlier threshold to account for the change in 
CCRs over time in a manner similar to that used for the FY 2007 IPPS. 
The commenter believed that it is appropriate to apply an adjustment 
factor to the CCRs, so that the CCRs CMS would use in simulations of 
outlier payments would more closely reflect the CCRs that would be used 
in CY 2007.
    Response: Given the potential difference in cost increases between 
inpatient and outpatient hospital departments, we do not believe it 
would be appropriate to apply the exact same CCR adjustment used under 
the IPPS without an OPPS-specific analysis. However, it is possible 
that a similar analysis specific to the OPPS could indicate that it 
would be appropriate to apply an OPPS CCR adjustment. We expect to 
study this issue further and would address any changes to the outlier 
methodology through future rulemaking.
    Comment: Some commenters objected to the lack of analysis to 
support the statement that the proposed outlier threshold would result 
in full payment of the outlier pool and urged CMS to publish the 
estimated outlier payments in the proposed rule, based on available 
data, to permit the public to better comment on the proposed outlier 
policy.
    Response: The proposed rule contained considerable discussion of 
the methodology we use to create the proposed outlier threshold, as 
well as the projected program expenditure amount that we use to 
determine the amount of the outlier set aside. Moreover, the claims we 
used for the simulation are available to the public. Indeed, the 
commenters perform many different types of analyses and often comment 
in extreme detail based on their analyses of the claims data and our 
description of the methodology we use to calculate the median costs on 
which the payment rates are based. Therefore, the public has every 
opportunity to perform a full and complete analysis of our outlier 
projections in preparation for commenting on the proposed outlier 
policy.
    Comment: One commenter objected to the payment of 50 percent of the 
cost that exceeds the threshold and believed that CMS should pay 80 
percent of the cost rather than 50 percent to ameliorate the level of 
losses that major teaching hospitals incur to provide complex 
outpatient services and to make outlier payment under the OPPS 
consistent with IPPS outlier payment.
    Response: We disagree with the commenter that we should pay 80 
percent of the cost that exceeds the threshold to ameliorate the level 
of losses that major teaching hospitals incur and to make outlier 
payment under the OPPS consistent with outlier payment under the IPPS. 
As we have explained, if we increase the percent of the excess over 
cost, in particular by 30 percent more than our proposed level of 50 
percent, the threshold would need to be greatly increased to avoid 
paying more than the 1.0 percent we have allowed for outlier payments. 
Moreover, we do not believe that it is appropriate to have the same 
policy governing outlier payment under both the IPPS and the OPPS 
because of the inherent differences in the clinical cases and payment 
methodologies that characterize the two systems. The circumstances 
giving rise to outlier payments under each system are not found in the 
other system, and therefore applying the same outlier policies would 
likely be contrary to the reasons behind each policy.
    After carefully considering the public comments received, we are 
finalizing our proposed policy for CY 2007 outlier payments. 
Recalculation of the fixed outlier threshold using this methodology 
results in a fixed-dollar outlier threshold of $1,825 and a multiple 
threshold of 1.75, based on an outlier estimate of 1.0 percent of 
payments projected to be made under the CY 2007 OPPS and outlier 
payments to be made at 50 percent of the amount by which the cost of 
furnishing the service exceeds 1.75 times the APC rate. The following 
is an example of an outlier calculation for CY 2007 under our final 
policy with this modification. A hospital charges $26,000 for a 
procedure. The wage adjusted, and rural adjusted, if applicable, APC 
payment for the procedure is $3,000. The provider's overall CCR is 
0.30. The estimated cost to the hospital is $7,800 (0.30 x $26,000). To 
determine whether this provider is eligible for outlier payments for 
this procedure, the provider must determine whether the cost for the 
service exceeds both the APC outlier cost threshold (1.75 x APC 
payment) and the fixed-dollar threshold ($1,825 + APC payment). In this 
example, the provider meets both criteria:
    (1) $7,800 exceeds $5,250 (1.75 x $3,000).
    (2) $7,800 exceeds $4,825 ($3,000 + $1,825).
    To calculate the outlier payment, which is 50 percent of the amount 
by which the cost of furnishing the service exceeds 1.75 times the APC 
rate, subtract $5,250 (1.75 x $3,000) from $7,800 (resulting in 
$2,550). The provider is eligible for 50 percent of the difference, in 
this case $1,275 ($2,550/2). The formula is (cost - (1.75 x APC payment 
rate))/2.

H. Calculation of the OPPS National Unadjusted Medicare Payment

    The basic methodology for determining prospective payment rates for 
OPD services under the OPPS is set forth in existing regulations at 
Sec.  419.31 and Sec.  419.32. The payment rate for services and 
procedures for which payment is made under the OPPS is the product of 
the conversion factor calculated in accordance with section II.C. of 
this final rule with comment period and the relative weight determined 
under section II.A. of this final rule with comment period. Therefore, 
the national unadjusted payment rate for each APC contained in Addendum 
A to this final rule with comment period and for HCPCS codes to which 
payment under the OPPS has been assigned in Addendum B to this final 
rule with comment period (Addendum B is provided as a convenience for 
readers) was calculated by multiplying the final CY 2007 scaled

[[Page 68013]]

weight for the APC by the final CY 2007 conversion factor.
    However, to determine the payment that will be made in a calendar 
year under the OPPS to a specific hospital for an APC for a service 
that has a status indicator of ``S,'' ``T,'' ``V,'' or ``X'' in a 
circumstance in which the multiple procedure discount does not apply, 
we take the following steps:
    Step 1. Calculate 60 percent (the labor-related portion) of the 
national unadjusted payment rate. Since the initial implementation of 
the OPPS, we have used 60 percent to represent our estimate of that 
portion of costs attributable, on average, to labor. (Refer to the 
April 7, 2000 final rule with comment period (65 FR 18496 through 
18497) for a detailed discussion of how we derived this percentage.)
    Step 2. Determine the wage index area in which the hospital is 
located and identify the wage index level that applies to the specific 
hospital. The wage index values assigned to each area reflect the new 
geographic statistical areas as a result of revised OMB standards 
(urban and rural) to which hospitals are assigned for FY 2007 under the 
IPPS, reclassifications through the Medicare Classification Geographic 
Review Board, section 1866(d)(8)(B) ``Lugar'' hospitals, and section 
401 of Pub. L. 108-173, and the reclassifications of hospitals under 
the one-time appeals process under section 508 of Pub. L. 108-173. The 
wage index values include the occupational mix adjustment described in 
section II.D. of this final rule with comment period that was developed 
for the final FY 2007 IPPS payment rates and finalized in the IPPS 
notice published in the Federal Register on October 11, 2006 (71 FR 
59886). These finalized FY 2007 IPPS wage indices, which are effective 
October 1, 2007, have been adjusted 100 percent for differences in 
occupational mix. As is our practice, we adopt changes made to the FY 
2007 IPPS wage index values after they have been finalized.
    Step 3. Adjust the wage index of hospitals located in certain 
qualifying counties that have a relatively high percentage of hospital 
employees who reside in the county, but who work in a different county 
with a higher wage index, in accordance with section 505 of Pub. L. 
108-173. Addendum L contains the qualifying counties and the finalized 
wage index increase developed for the FY 2007 IPPS (71 FR 59886). This 
step is to be followed only if the hospital has chosen not to accept 
reclassification under Step 2 above.
    Step 4. Multiply the applicable wage index determined under Steps 2 
and 3 by the amount determined under Step 1 that represents the labor-
related portion of the national unadjusted payment rate.
    Step 5. Calculate 40 percent (the nonlabor-related portion) of the 
national unadjusted payment rate and add that amount to the resulting 
product of Step 4. The result is the wage index adjusted payment rate 
for the relevant wage index area.
    Step 6. If a provider is a SCH, as defined in Sec.  412.92, and 
located in a rural area, as defined in Sec.  412.63(b), or is treated 
as being located in a rural area under Sec.  412.103 of the Act, 
multiply the wage index adjusted payment rate by 1.071 to calculate the 
total payment.
    We did not receive any public comments on our proposed methodology 
for calculating the national unadjusted Medicare payment amount for CY 
2007. Therefore, we are finalizing our proposed methodology for CY 2007 
without modification.

I. Beneficiary Copayments for CY 2007

1. Background
    Section 1833(t)(3)(B) of the Act requires the Secretary to set 
rules for determining copayment amounts to be paid by beneficiaries for 
covered OPD services. Section 1833(t)(8)(C)(ii) of the Act specifies 
that the Secretary must reduce the national unadjusted copayment amount 
for a covered OPD service (or group of such services) furnished in a 
year in a manner so that the effective copayment rate (determined on a 
national unadjusted basis) for that service in the year does not exceed 
specified percentages. For all services paid under the OPPS in CY 2007, 
and in calendar years thereafter, the specified percentage is 40 
percent of the APC payment rate (section 1833(t)(8)(C)(ii)(V) of the 
Act). Section 1833(t)(3)(B)(ii) of the Act provides that, for a covered 
OPD service (or group of such services) furnished in a year, the 
national unadjusted coinsurance amount cannot be less than 20 percent 
of the OPD fee schedule amount.
    Sections 1834(d) (2) and (d)(3) of the Act further require Medicare 
to pay the lesser of the ASC or OPPS payment rate for screening 
flexible sigmoidoscopies and screening colonoscopies, with coinsurance 
equal to 25 percent of the payment amount. We have applied the 25-
percent coinsurance to all of these services since the beginning of the 
OPPS. Medicare does not make payment to ASCs for screening 
sigmoidoscopies so there is no payment comparison to be made for those 
services. However, for CY 2007, the OPPS payment for screening 
colonoscopies, HCPCS codes G0105 (Colorectal cancer screening; 
colonoscopy on individual at risk) and G0121 (Colorectal cancer 
screening; colonoscopy on individual not meeting criteria for high 
risk), developed in accordance with our standard OPPS ratesetting 
methodology, would exceed the ASC payment of $446 for these procedures. 
Therefore, for CY 2007, the OPPS payment rates for HCPCS codes G0105 
and G0121 that describe screening colonoscopies will be set to equal 
the CY 2007 ASC rate of $446 for these services.
2. Copayment for CY 2007
    For CY 2007, we proposed to determine copayment amounts for new and 
revised APCs using the same methodology that we implemented for CY 
2004. (Refer to the November 7, 2003 OPPS final rule with comment 
period, 68 FR 63458.) These unadjusted copayment amounts for services 
payable under the OPPS that will be effective January 1, 2007, are 
shown in Addendum A and Addendum B of this final rule with comment 
period.
3. Calculation of an Adjusted Copayment Amount for an APC Group for CY 
2007
    To calculate the OPPS adjusted copayment amount for an APC group, 
take the following steps:
    Step 1. Calculate the beneficiary payment percentage for the APC by 
dividing the APC's national unadjusted copayment by its payment rate. 
For example, using APC 0001, $7.00 is 23 percent of $30.21.
    Step 2. Calculate the wage adjusted payment rate for the APC, for 
the provider in question, as indicated in section II.H. of this 
preamble. Calculate the rural adjustment for eligible providers as 
indicated in section I.H. of this preamble.
    Step 3. Multiply the percentage calculated in Step 1 by the payment 
rate calculated in Step 2. The result is the wage-adjusted copayment 
amount for the APC.
    The unadjusted copayments for services payable under the OPPS that 
will be effective January 1, 2007, are shown in Addendum A and Addendum 
B of this final rule with comment period.
    We did not receive any public comments concerning our methodology 
for calculating the beneficiary unadjusted copayment amount. Therefore, 
we are finalizing our proposed methodology for CY 2007 without 
modification.

[[Page 68014]]

III. OPPS Ambulatory Payment Classification (APC) Group Policies

A. Treatment of New HCPCS and CPT Codes

1. Treatment of New HCPCS Codes Included in the Second and Third 
Quarterly OPPS Updates for CY 2006
    During the second and third quarters of CY 2006, we created a total 
of four new Level II HCPCS codes, specifically C9227, C9228, C9229, and 
C9230 that were not addressed in the November 10, 2005 final rule with 
comment period that updated the CY 2006 OPPS. We designated the payment 
status of these codes and added them either through the April update 
(Transmittal 896, dated March 24, 2006) or the July update of the CY 
2006 OPPS (Transmittal 970, dated May 30, 2006). In the CY 2007 OPPS 
proposed rule, we also solicited public comments on the status 
indicators and APC assignments of these codes, which were listed in 
Table 5 of that proposed rule (71 FR 49548), and now appear in Table 5 
of this final rule with comment period. Because of the timing of the 
proposed rule, the codes implemented in the July 2006 OPPS update were 
not included in Addendum B of that proposed rule, while those codes 
based upon the April 2006 OPPS update were included in Addendum B. In 
the CY 2007 OPPS proposed rule, we proposed to assign the new HCPCS 
codes for CY 2007 to the appropriate APCs and incorporate them into our 
final rule with comment period for CY 2007, which is consistent with 
our annual APC updating policy.
    We did not receive any public comments on the APC assignments and 
status indicators designated for C9227, C9228, C9229, or C9230 that 
were implemented in either April 2006 or July 2006. However, for CY 
2007, the National HCPCS Panel created permanent J-codes for each of 
these drugs. Consistent with our general policy of using permanent 
HCPCS codes if appropriate rather than C-codes for the reporting of 
drugs under the OPPS in order to streamline coding, we are showing the 
J-codes in Table 5 that replaced the C-codes, effective January 1, 
2007. C9227 is replaced with J2248 (Injection, micafungin sodium, 1 
mg); C9228 with J3243 (Injection, tigecycline, 1 mg); C9229 with J1740 
(Injection, ibandronate sodium, 1 mg); and C9230 with J0129 (Injection, 
abatacept, 10 mg). The J-codes describe the same drugs and the same 
dosages as the C-codes that will be deleted December 31, 2006. We note 
that C-codes are temporary national HCPCS codes. To avoid duplication, 
temporary national HCPCS codes, such as C, G, K, and Q codes, are 
generally deleted once permanent national HCPCS codes are created that 
describe the same item, service, or procedure. Because the four new J-
codes describe the same drugs and the same dosages that are currently 
designated by C9227, C9228, C9229, and C9230 and all four of these 
drugs will continue with pass-through status in CY 2007, we are 
assigning the J-codes to the same APCs and status indicators as their 
predecessor C-codes, as shown in Table 5. That is, J2248 will be 
assigned to the same APC and status indicator as C9227; J3243 to APC 
9228; J1740 to APC 9229; and J0129 to APC 9230. Because we received no 
public comments on the APC and status indicator assignments for the new 
HCPCS codes that were implemented in April or July 2006, we are 
adopting as final without modification, our proposal to assign their 
replacement HCPCS J-codes to the appropriate APCs, as shown in Addendum 
B of this final rule with comment period.

                           Table 5.--New HCPCS Codes Implemented in April or July 2006
----------------------------------------------------------------------------------------------------------------
  New HCPCS J-Code effective                                                   Assigned status
       January 1, 2007              HCPCS C-Code           Description            indicator        Assigned APC
----------------------------------------------------------------------------------------------------------------
J2248........................  C9227................  Injection,            G...................            9227
                                                       micafungin sodium,
                                                       per 1 mg.
J3243........................  C9228................  Injection,            G...................            9228
                                                       tigecycline, per 1
                                                       mg.
J1740........................  C9229................  Injection,            G...................            9229
                                                       ibandronate sodium,
                                                       per 1 mg.
J0129........................  C9230................  Injection,            G...................            9230
                                                       abatacept, per 10
                                                       mg.
----------------------------------------------------------------------------------------------------------------

2. Treatment of New CY 2007 Category I and III CPT Codes and Level II 
HCPCS Codes
    As has been our practice in the past, we implement new Category I 
and III CPT codes and new Level II HCPCS codes, which are released in 
the summer through the fall of each year for annual updating, effective 
January 1, in the final rule updating the OPPS for the following 
calendar year. These codes are flagged with comment indicator ``NI'' in 
Addendum B of the OPPS final rule to indicate that we are assigning 
them an interim payment status which is subject to public comment 
following publication of the final rule that implements the annual OPPS 
update. (See the discussion immediately below concerning our modified 
policy for implementing new Category I and III mid-year CPT codes.) In 
our CY 2007 OPPS proposed rule, we proposed to continue this 
recognition and process for CY 2007. Therefore, new Category I and III 
CPT codes and new Level II HCPCS codes, effective January 1, 2007, are 
listed in Addendum B of this final rule with comment period and 
designated using comment indicator ``NI.'' The status indicator, the 
APC assignment, or both, for all such codes flagged with Comment 
Indicator ``NI'' are open to public comment. As indicated in the CY 
2007 OPPS proposed rule, we will respond to all comments received 
concerning these codes in a subsequent final rule for the next calendar 
year's OPPS update.
    We received some comments to the CY 2007 proposed rule regarding 
individual new HCPCS codes that commenters expected to be implemented 
for the first time in the CY 2007 OPPS. We could not discuss APC and/or 
status indictor assignments for new CY 2007 HCPCS codes in the proposed 
rule because the codes were not available when we developed and issued 
the proposed rule. For those new Category I CPT codes whose descriptors 
were not officially available during the comment period and development 
of the CY 2007 final rule with comment period, we do not specifically 
respond to those comments in this final rule with comment period. For 
those new Category III CPT codes that were released on July 1, 2006, 
for implementation January 1, 2007, we respond to those comments in 
this final rule with comment period because those codes were publicly 
available during the comment period to the proposed rule and the 
development of this final rule with comment period. Both of these 
groups of codes are flagged with comment indicator ``NI'' in this final 
rule with comment period, as discussed above, to signal that they are 
open to public comment.

[[Page 68015]]

    Two new G-codes for CY 2007 that are assigned comment indicator 
``NI'' in this final rule with comment period were developed to enable 
clinicians and facilities to specifically report transluminal balloon 
angioplasty to existing arteriovenous fistulas or prosthetic grafts for 
hemodialysis access. Currently, there are no CPT or alphanumeric HCPCS 
codes on the ASC list that would provide payment to ASCs for providing 
this service to Medicare patients with failing or stenotic hemodialysis 
access fistulas or grafts. There are no CPT codes that are specific to 
this particular service. Therefore, we are creating two Level II HCPCS 
G-codes for implementation in CY 2007: (1) G0392 (Transluminal balloon 
angioplasty, percutaneous, hemodialysis access fistula or graft; 
arterial) and (2) G0393 (Transluminal balloon angioplasty, 
percutaneous, hemodialysis access fistula or graft; venous). We will 
provide payment for these G-codes at the same OPPS rates as for CPT 
codes 35475 (Transluminal balloon angioplasty, percutaneous; 
brachiocephalic trunk or branches, each vessel) and 35476 (Transluminal 
balloon angioplasty, percutaneous; venous) through APC 0081 (Non-
Coronary Angioplasty or Atherectomy), with a CY 2007 final median cost 
of $2,450.64. We will also assign both G-codes to payment group 9 for 
ASC payment in CY 2007. The G-codes will be used by hospital outpatient 
departments and ASCs to report transluminal balloon angioplasty of 
hemodialysis access fistulas or grafts in these settings.
    Beginning in CY 2007, CPT codes 35475 and 35476 should not be 
reported for patients undergoing percutaneous transluminal balloon 
angioplasty of hemodialysis access fistulas or grafts. Both CPT codes 
will remain active to report all other clinical services that would be 
described by these codes.
    We did not receive any public comments on our proposal to assign a 
comment indicator of ``NI'' in Addendum B of the OPPS final rule to the 
new codes that are open to public comment. Therefore, we are finalizing 
our proposed treatment of new CY 2007 Category I and III CPT codes, as 
well as the Level II HCPCS codes, without modification.
3. Treatment of New Mid-Year CPT Codes
    Twice each year, the AMA issues Category III CPT codes, which the 
AMA defines as temporary codes for emerging technology, services, and 
procedures. (In addition, the AMA issues mid-year Category I CPT codes 
for vaccines for which FDA approval is imminent, to ensure timely 
availability of a code.) The AMA establishes these codes to allow 
collection of data specific to the service described by the code, as 
these services could otherwise only be reported using a Category I CPT 
unlisted code. The AMA releases Category III CPT codes in January, for 
implementation beginning the following July, and in July, for 
implementation beginning the following January. Prior to CY 2006, we 
treated new Category III CPT codes implemented in July of the previous 
year or January of the OPPS update year in the same manner that new 
Category I CPT codes and new Level II HCPCS codes implemented in 
January of the OPPS update year are treated; that is, we provided APC 
or status indicator assignments or both in the final rule updating the 
OPPS for the following calendar year. New Category I and Category III 
CPT codes, as well as new Level II HCPCS codes, were flagged with 
comment indicator ``NI'' in Addendum B of the final rule to indicate 
that we assigned them an interim payment status which was subject to 
public comment following publication of the final rule that implemented 
the annual OPPS update.
    As discussed in the CY 2006 OPPS final rule with comment period (70 
FR 68567), we modified our process for implementing the Category III 
codes that the AMA releases each January for implementation in July to 
ensure timely collection of data pertinent to the services described by 
the codes; to ensure patient access to the services the codes describe; 
and to eliminate potential redundancy between Category III CPT codes 
and some of the C-codes that are payable under the OPPS and were 
created by us in response to applications for new technology services. 
Therefore, beginning on July 1, 2006, we implemented in the OPPS seven 
Category III CPT codes that the AMA released in January 2006 for 
implementation in July 2006. These codes were shown in Table 6 of the 
CY 2007 OPPS proposed rule (71 FR 49549). They were not included in 
Addendum B of that rule, which was based upon the April 2006 OPPS 
update. In the CY 2007 OPPS proposed rule, we solicited public comments 
on the status indicators and, if applicable, the APC assignments of 
these services. We proposed in the CY 2007 OPPS proposed rule to 
finalize the assignments of these Category III CPT codes implemented in 
July 2006 in this final rule with comment period.
    As indicated in the CY 2007 OPPS proposed rule (71 FR 49549), some 
of the new Category III CPT codes describe services that we have 
determined to be similar in clinical characteristics and resource use 
to HCPCS codes in an existing APC. In these instances, we may assign 
the Category III CPT code to the appropriate clinical APC. Other 
Category III CPT codes describe services that we have determined are 
not compatible with an existing clinical APC, yet are appropriately 
provided in the hospital outpatient setting. In these cases, we may 
assign the Category III CPT code to what we estimate is an 
appropriately priced New Technology APC. In other cases, we may assign 
a Category III CPT code to one of several nonseparately payable status 
indicators, including ``N,'' ``C,'' ``B,'' or ``E,'' which we believe 
is appropriate for the specific code. We expect that we will have 
received applications for new technology status for some of the 
services described by new Category III CPT codes, which may assist us 
in determining appropriate APC assignments. If the AMA establishes a 
Category III CPT code for a service for which an application has been 
submitted to CMS for new technology status, CMS may not have to issue a 
temporary Level II HCPCS code to describe the service, as has often 
been the case in the past when Category III CPT codes were only 
recognized by the OPPS on an annual basis.
    Therefore, for CY 2007, we proposed to include in Addendum B of 
this final rule with comment period, the new Category III CPT codes and 
the new Category I CPT codes for vaccines released in January 2006 for 
implementation on July 1, 2006 (through the OPPS quarterly update 
process) and the Category III and vaccine Category I CPT codes released 
in July 2006 for implementation on January 1, 2007. However, only those 
new Category III CPT codes and the new vaccine codes implemented 
effective January 1, 2007, are flagged with comment indicator ``NI'' in 
Addendum B of this final rule with comment period to indicate that we 
have assigned them an interim payment status which is subject to public 
comment. As discussed earlier, Category III CPT codes implemented in 
July 2006, which appear in Table 6, were subject to comment through the 
CY 2007 OPPS proposed rule and their statuses are finalized in this 
final rule with comment period.

[[Page 68016]]



                            Table 6.--Category III CPT Codes Implemented in July 2006
----------------------------------------------------------------------------------------------------------------
                                        Proposed CY 2007    Proposed CY 2007     Final CY 2007     Final CY 2007
     CPT code        Long descriptor    status indicator           APC          status indicator        APC
----------------------------------------------------------------------------------------------------------------
0155T.............  Laparoscopy,       T.................  0130..............  T................            0130
                     surgical,
                     implantation or
                     replacement of
                     gastric
                     stimulation
                     electrodes,
                     lesser curvature
                     (ie, morbid
                     obesity).
0156T.............  Laparoscopy,       T.................  0130..............  T................            0130
                     surgical,
                     revision or
                     removal of
                     gastric
                     stimulation
                     electrodes,
                     lesser curvature
                     (ie, morbid
                     obesity).
0157T.............  Laparotomy,        C.................
                     implantation or
                     replacement of
                     gastric
                     stimulation
                     electrodes,
                     lesser curvature
                     (ie, morbid
                     obesity).
0158T.............  Laparotomy,        C.................
                     revision or
                     removal of
                     gastric
                     stimulation
                     electrodes,
                     lesser curvature
                     (ie, morbid
                     obesity).
0159T.............  Computer-aided     N.................
                     detection,
                     including
                     computer
                     algorithm
                     analysis of MRI
                     image data for
                     lesion detection/
                     characterization
                     ,
                     pharmacokinetic
                     analysis, with
                     further
                     physician review
                     for
                     interpretation,
                     breast MRI.
0160T.............  Therapeutic        X.................  0340..............  S................            0216
                     repetitive
                     transcranial
                     magnetic
                     stimulation
                     treatment
                     planning.
0161T.............  Therapeutic        X.................  0340..............  S................            0216
                     repetitive
                     transcranial
                     magnetic
                     stimulation
                     treatment
                     delivery and
                     management, per
                     session.
----------------------------------------------------------------------------------------------------------------

    We received several public comments on the proposed APC assignments 
for Category III CPT codes 0159T, 0160T, and 0161T. A summary of the 
comments and our responses follows:
    Comment: One commenter requested that CMS assign CPT code 0159T to 
an APC that is separately payable under the OPPS because there are 
additional resources associated with performing a breast MRI with 
computer-aided detection (CAD), which is a significant advancement in 
early detection and treatment for possible breast cancers. The 
commenter indicated that the procedure described by CPT code 0159T is 
similar to the CAD procedures that are associated with mammography, 
which CMS previously recognized and allowed separate payment. The 
commenter urged CMS to pay separately for CPT code 0159T, if not 
through the hospital OPPS, then by a separate payment under the MFPS, 
similar to other hospital-based mammography services.
    Response: The CAD procedures that the commenter makes reference to 
are described by CPT codes 77051 (Computer-aided detection (computer 
algorithm analysis of digital image data for lesion detection) with 
further physician review for interpretation, with or without 
digitization of film radiographic images; diagnostic mammography) and 
77052 (Computer-aided detection (computer algorithm analysis of digital 
image data for lesion detection) with further physician review for 
interpretation, with or without digitization of film radiographic 
images; screening mammography). These are both paid off the MPFS, 
according to specific provisions in the law for screening and 
diagnostic mammography that specify that such services, when performed 
in the hospital outpatient setting, are paid according to the MPFS. 
Other hospital outpatient imaging services, such as CPT code 0159T, are 
paid under the OPPS. We have assigned this service packaged payment 
status under the OPPS for CY 2007, because we believe that it is a 
minor ancillary service that would always be provided in association 
with another separately payable service (mostly likely an MRI), into 
which its payment would be appropriately packaged. As a prospective 
payment system, the OPPS makes payment for groups of services that are 
clinically coherent with similar resource utilization and packages 
payment for many items, supplies, and minor associated services into 
the payment for the primary service. Our final CY 2007 treatment of CPT 
code 0159T is the same as our final CY 2007 packaged status for two 
chest x-ray CAD services, CPT code 0174T (Computer-aided detection 
(CAD) (computer algorithm analysis of digital image data for lesion 
detection) with further physician review for interpretation and report, 
with or without digitization of film radiographic images, chest 
radiograph(s), performed concurrent with primary interpretation) and 
CPT code 0175T (Computer aided detection (CAD) (computer algorithm 
analysis of digital image data for lesion detection) with further 
physician review for interpretation and report, with or without 
digitization of film radiographic images, chest radiograph(s), 
performed remote from primary interpretation) that is discussed further 
in section II.A.4. of this final rule with comment period.
    Comment: One commenter requested that CMS not map Category III CPT 
codes 0160T and 0161T to APC 0340 (Minor Ancillary Procedures) because 
the technology associated with these procedures is currently under 
review by the FDA and approval is not expected until January 2007. The 
commenter indicated that these codes describe therapeutic transcranial 
magnetic stimulation (TMS) therapy, which is used for the treatment of 
major depression. The commenter further indicated that TMS therapy 
represents a procedure that involves a complex brain mapping and 
stimulation treatment process and requires the use of specific 
equipment and a specialized operator skill set. As such, the commenter 
concluded that TMS therapy represents a procedure whose hospital 
resources are significantly greater than reflected by the proposed 
payment rate for APC 0340 of about $38. The commenter believed that 
mapping Category III CPT codes 0160T and 0161T to APC 0340, or to any 
other APCs, is inappropriate at this time because the costs of these 
services are currently not known. The commenter cautioned that 
assigning these codes to specific APCs would be arbitrary and could 
significantly overcompensate or undercompensate providers because there 
are no cost data available to appropriately map codes 0160T and 0161T 
at this time. The commenter acknowledged that not assigning the two 
codes to specific APCs may result in no payment for TMS therapy 
performed in hospital outpatient settings for CY 2007 and likely limit 
access for some patients. However, the commenter indicated that it 
plans to work with the APC Panel in CY 2007 to determine the 
appropriate mapping for the two codes to ensure access for appropriate 
patients.
    Other commenters noted that there was a related Category III code, 
CPT code 0018T (Delivery of high power,

[[Page 68017]]

focal magnetic pulses for direct stimulation to cortical neurons) that 
was created prior to the full maturation of the therapeutic TMS 
procedure and related technology. The commenters noted differences 
between CPT code 0018T and the two new Category III CPT codes, 
including its lack of incorporation of the treatment planning function, 
its failure to specify repetitive in the descriptor, and its lack of 
description of therapeutic treatment delivery. They believed that the 
historical APC assignment of code 0018T to APC 0215 (Level I Nerve and 
Muscle Tests) was inappropriate, although one commenter stated that it 
was not involved in determining that mapping. The commenters pointed 
out that there are also two Category I CPT codes that incorporate TMS 
for diagnostic purposes, including CPT code 95928 (Central motor evoked 
potential study (transcranial motor stimulation); upper limbs) and CPT 
code 95929 (Central motor evoked potential study (transcranial motor 
simulation); lower limbs). The commenters added that both of these 
codes were proposed for assignment to APC 0218 (Level II Nerve and 
Muscle Tests) for CY 2007 with a payment rate of about $74.
    Response: We appreciate the commenters' suggestion and background 
information. However, because the CPT code descriptors are general in 
nature and not specific to a particular product, our policy has been to 
assign an APC to each Category III CPT code if we believe that the 
procedure, if covered, would be appropriate for separate payment in the 
OPPS.
    In addition, as indicated in the CY 2006 OPPS final rule (70 FR 
68567), some of the new Category III CPT codes may describe services 
that our medical advisors determine to be similar in clinical 
characteristics and resource use to HCPCS codes in an existing APC. In 
such instances, we may assign the Category III CPT code to the 
appropriate clinical APC. Other Category III CPT codes may describe 
services that our medical advisors determine are not compatible with an 
existing clinical APC, yet are appropriately provided in the hospital 
outpatient setting. In these cases, we may assign the Category III CPT 
code to what we estimate is an appropriately priced New Technology APC. 
In the case of CPT codes 0160T and 0161T, we believe the services 
described by these active CPT codes would be appropriately separately 
paid under the OPPS if they are covered. We do not believe the 
technology used to provide these services is so new that their 
assignment to New Technology APCs would be appropriate. Although our 
final determination regarding these two codes is to provide assignments 
to specific APCs with payment rates for CY 2007 as described below, 
this decision does not represent a determination that the services 
described by Category III CPT codes 0160T and 0161T are reasonable and 
necessary. Medicare contractors determine whether the services 
described by all HCPCS codes with status indicators reflecting their 
potential for payment under the OPPS, including Category III CPT codes, 
meet all the program requirements for coverage in different clinical 
circumstances.
    The Internet listing of Category III code changes on the AMA Web 
site includes a parenthetical note that CPT Code 0018T has been deleted 
as of July 1, 2006, the same date new CPT codes 0160T and 0161T were 
first implemented. The note also indicates that, to report the 
procedure previously described by 0018T, one should see CPT codes 0160T 
and 0161T. CPT Changes, an Insider's View for CY 2002 when 0018T was 
created, describes the use of CPT code 0018T for treatment of a patient 
with a long history of depression, incorporating planning and 
therapeutic treatment delivery in the description of the procedure. In 
general, that outline of the service described by CPT code 0018T 
closely parallels the clinical vignettes for CPT codes 0160T and 0161T 
that were provided to us in a public comment. Therefore, we do not 
agree with the commenters that our historical claims for 0018T must be 
instances of miscoding or the use of TMS for diagnostic purposes. While 
we had no claims for CPT code 0018T for CY 2005, we do have claims data 
for this service from CYs 2002 through 2004, although there were fewer 
than 15 total claims for each of those years. The procedure was 
assigned to APC 0215 (Level I Nerve and Muscle Tests) with a payment 
rate of about $35 throughout that time period, with no specific 
comments from the public on this assignment during the OPPS proposed 
updates for those years.
    We understand that the hospital resource costs of specific 
technologies may change over time as those technologies evolve. In 
reviewing the clinical aspects of CPT codes 0160T and 0161T, in the 
context of related codes and our historical OPPS claims data for CPT 
code 0018T and other services, we agree with the commenter that APC 
0340 is not the most appropriate assignment for CPT codes 0160T and 
0161T for CY 2007. The commenter provided no specific suggestions 
regarding the APC assignments for these codes. As discussed earlier, 
CPT codes describe general services that are not specific to one 
product, and we believe it is most appropriate to provide APC 
assignments for all new HCPCS codes that would be appropriately 
separately paid under the OPPS if they were covered. This approach 
helps ensure access to services described by these codes for Medicare 
beneficiaries in the hospital outpatient department and allows us to 
initiate collection of hospital cost information as soon as possible. 
The commenter indicated that TMS may be safely performed in the 
hospital outpatient setting. We do not see any reason to provide the 
Category III CPT codes for TMS nonpayable status indicators in the OPPS 
for CY 2007, when the codes were implemented in July 2006 and there are 
no alternative HCPCS codes to describe the services. However, we 
believe that APC 0216 (Level III Nerve and Muscle Tests) best 
represents both the clinical and resource homogeneity of CPT codes 
0160T and 0161T for CY 2007, considering all of the information 
available to us. We note that this APC has a status indicator of ``S,'' 
so that under the occasional circumstance of two treatments in one day 
for a single patient as described by a commenter, payment would not be 
reduced for the second service. We will reevaluate these assignments 
for future OPPS updates as additional information becomes available to 
us, including updated claims data.
    After carefully considering the comments received, we are 
finalizing our general proposal for the treatment of new mid-year CPT 
codes, with modification only to the CY 2007 APC assignments for 
Category III CPT codes 0160T and 0161T as described above and indicated 
in Table 6.

B. Variations Within APCs

1. Background
    Section 1833(t)(2)(A) of the Act requires the Secretary to develop 
a classification system for covered hospital outpatient services. 
Section 1833(t)(2)(B) of the Act provides that this classification 
system may be composed of groups of services, so that services within 
each group are comparable clinically and with respect to the use of 
resources. In accordance with these provisions, we developed a grouping 
classification system, referred to as the Ambulatory Payment 
Classification Groups (or APCs), as set forth in Sec.  419.31 of the 
regulations. We use Level I and Level II HCPCS codes and descriptors to 
identify and group the services within each APC. The APCs

[[Page 68018]]

are organized such that each group is homogeneous both clinically and 
in terms of resource use. Using this classification system, we have 
established distinct groups of surgical, diagnostic, and partial 
hospitalization services, as well as medical visits. We also have 
developed separate APC groups for certain medical devices, drugs, 
biologicals, radiopharmaceuticals, and brachytherapy devices.
    We have packaged into each procedure or service within an APC group 
the costs associated with those items or services that are directly 
related and integral to performing a procedure or furnishing a service. 
Therefore, we do not make separate payment for packaged items or 
services. For example, packaged items and services include: (1) Use of 
an operating, treatment, or procedure room; (2) use of a recovery room; 
(3) most observation services; (4) anesthesia; (5) medical/surgical 
supplies; (6) pharmaceuticals (other than those for which separate 
payment may be allowed under the provisions discussed in section V of 
this preamble); and (7) incidental services such as venipuncture. Our 
proposed packaging methodology is discussed in section II.A. of this 
preamble.
    Under the OPPS, we pay for hospital outpatient services on a rate-
per-service basis that varies according to the APC group to which the 
service is assigned. Each APC weight represents the hospital median 
cost of the services included in that APC relative to the hospital 
median cost of the services included in APC 0606. The APC weights are 
scaled to APC 0606 because we are proposing it to be the middle level 
clinic visit APC (that is, where the Level III Clinic Visit HCPCS code 
of five levels of clinic visits is assigned), and because middle level 
clinic visits are among the most frequently furnished services in the 
outpatient hospital setting. See section II.A.3. of this preamble for a 
complete discussion of the reasons for choosing APC 0606 as the basis 
for scaling the APC relative weights.
    Section 1833(t)(9)(A) of the Act requires the Secretary to review 
the components of the OPPS not less than annually and to revise the 
groups and relative payment weights and make other adjustments to take 
into account changes in medical practice, changes in technology, and 
the addition of new services, new cost data, and other relevant 
information and factors. Section 1833(t)(9)(A) of the Act, as amended 
by section 201(h) of the BBRA of 1999, also requires the Secretary, 
beginning in CY 2001, to consult with an outside panel of experts to 
review the APC groups and the relative payment weights (the APC Panel 
recommendations for specific services for CY 2007 OPPS and our 
responses to them are discussed in the relevant specific sections 
throughout this preamble).
    Finally, as discussed earlier, section 1833(t)(2) of the Act 
provides that, subject to certain exceptions, the items and services 
within an APC group cannot be considered comparable with respect to the 
use of resources if the highest median (or mean cost, if elected by the 
Secretary) for an item or service in the group is more than 2 times 
greater than the lowest median cost for an item or service within the 
same group (referred to as the ``2 times rule''). We use the median 
cost of the item or service in implementing this provision. The statute 
authorizes the Secretary to make exceptions to the 2 times rule in 
unusual cases, such as low-volume items and services.
    2. Application of the 2 Times Rule
    In accordance with section 1833(t)(2) of the Act and Sec.  419.31 
of the regulations, we annually review the items and services within an 
APC group to determine, with respect to comparability of the use of 
resources, if the median of the highest cost item or service within an 
APC group is more than 2 times greater than the median of the lowest 
cost item or service within that same group (``2 times rule''). We make 
exceptions to this limit on the variation of costs within each APC 
group in unusual cases such as low-volume items and services.
    During the APC Panel's March 2006 meeting, we presented median cost 
and utilization data for services furnished during the period of 
January 1, 2005, through September 30, 2005, about which we had 
concerns or about which the public had raised concerns regarding their 
APC assignments, status indicator assignments, or payment rates. The 
discussions of most service-specific issues, the APC Panel 
recommendations, if any, and our proposals for CY 2007 are contained 
principally in sections III.C. and III.D. of this preamble.
    In addition to the assignment of specific services to APCs which we 
discussed with the APC Panel, we also identified APCs with 2 times 
violations that were not specifically discussed with the APC Panel but 
for which we proposed changes to their HCPCS codes' APC assignments in 
Addendum B of the CY 2007 proposed rule. In these cases, to eliminate a 
2 times violation, we reassigned the codes to APCs that contained 
services that were similar with regard to both resource use and 
clinical homogeneity. We also proposed changes to the status indicators 
for some codes that were not specifically and separately discussed in 
the proposed rule. In these cases, we changed the status indicators for 
some codes because we believed that another status indicator more 
accurately described their payment status from an OPPS perspective 
based on our CY 2007 proposed policies.
    Addendum B of the CY 2007 OPPS proposed rule identified with a 
comment indicator ``CH'' those HCPCS codes for which we proposed a 
change to the APC assignment or status indicator as assigned in the 
April 2006 Addendum B update. Addendum B of this final rule with 
comment period identifies with the ``CH'' comment indicator the final 
CY 2007 changes compared to the codes'' status as reflected in the 
October 2006 Addendum B update.
    We received many public comments regarding the proposed APC and 
status indicator assignments for CY 2007 for specific HCPCS codes. 
These are discussed mainly in sections III.C. and III.D. of this final 
rule with comment period, and the final action for CY 2007 related to 
each HCPCS code is noted in those sections.
3. Exceptions to the 2 Times Rule
    As discussed earlier, we may make exceptions to the 2 times limit 
on the variation of costs within each APC group in unusual cases such 
as low-volume items and services. At the time of the proposed rule, 
taking into account the APC changes that we proposed for CY 2007 based 
on the APC Panel recommendations discussed mainly in sections III.C. 
and III.D. of the preamble, the proposed changes to status indicators 
and APC assignments as identified in Addendum B of the CY 2007 OPPS 
proposed rule, and the use of CY 2005 claims data to calculate the 
median costs of procedures classified in the APCs, we reviewed all the 
APCs to determine which APCs would not satisfy the 2 times rule. We 
used the following criteria to decide whether to propose exceptions to 
the 2 times rule for affected APCs:
     Resource homogeneity
     Clinical homogeneity
     Hospital concentration
     Frequency of service (volume)
     Opportunity for upcoding and code fragments.
    For a detailed discussion of these criteria, refer to the April 7, 
2000 OPPS final rule with comment period (65 FR 18457).
    Table 7 published in the CY 2007 OPPS proposed rule (71 FR 49551)

[[Page 68019]]

listed the APCs that we proposed to exempt from the 2 times rule based 
on the criteria cited above. For cases in which a recommendation by the 
APC Panel appeared to result in or allow a violation of the 2 times 
rule, we generally accepted the APC Panel's recommendation because 
those recommendations were based on explicit consideration of resource 
use, clinical homogeneity, hospital specialization, and the quality of 
the data used to determine the APC payment rates that we proposed for 
CY 2007. The median costs for hospital outpatient services for these 
and all other APCs which were used in development of the proposed rule 
can be found on the CMS Web site: http://www.cms.hhs.gov.
    We did not receive any general public comments related to the list 
of proposed exceptions to the 2 times rule. We received a number of 
specific comments about some of the procedures assigned to APCs that we 
proposed to make exempt from the 2 times rule for CY 2007. Those 
discussions are elsewhere in the preamble, in sections related to the 
types of procedures that were the subjects of the comments.
    For the proposed rule, the listed exceptions to the 2 times rule 
were based on data from January 1, 2005, through September 30, 2005. 
For this final rule with comment period, we used data from January 1, 
2005 through December 1, 2005. Thus, after responding to all of the 
comments on the proposed rule and making changes to APC assignments 
based on those comments, we analyzed the full CY 2005 data to identify 
APCs with 2 times rule violations.
    Based on those final data, we found that there were 37 APCs with 2 
times rule violations. We applied the criteria as described earlier to 
finalize the APCs that are exceptions to the 2 times rule for CY 2007. 
The final revised list of APCs that are exceptions to the 2 times rule 
for CY 2007 is displayed in Table 7 below. After careful review of all 
public comments on the proposed rule and the claims data for the full 
year, CY 2005, available to us for this final rule with comment period, 
we are finalizing the list of APCs exempted from the two times rule as 
displayed in Table 7 below.

        Table 7.--APC Exceptions to the 2 Times Rule for CY 2007
------------------------------------------------------------------------
              APC                            APC description
------------------------------------------------------------------------
0007..........................  Level II Incision & Drainage.
0010..........................  Level I Destruction of Lesion.
0019..........................  Level I Excision/ Biopsy.
0024..........................  Level I Skin Repair.
0040..........................  Percutaneous Implantation of
                                 Neurostimulator Electrodes, Excluding
                                 Cranial Nerve.
0043..........................  Closed Treatment Fracture Finger/Toe/
                                 Trunk.
0058..........................  Level I Strapping and Cast Application.
0060..........................  Manipulation Therapy.
0081..........................  Non-Coronary Angioplasty or Atherectomy.
0093..........................  Vascular Reconstruction/Fistula Repair
                                 without Device.
0105..........................  Revision/Removal of Pacemakers, AICD, or
                                 Vascular.
0111..........................  Blood Product Exchange.
0112..........................  Apheresis, Photopheresis, and
                                 Plasmapheresis.
0203..........................  Level IV Nerve Injections.
0204..........................  Level I Nerve Injections.
0215..........................  Level I Nerve and Muscle Tests.
0245..........................  Level I Cataract Procedures without IOL
                                 Insert.
0251..........................  Level I ENT Procedures.
0252..........................  Level II ENT Procedures.
0274..........................  Myelography.
0303..........................  Treatment Device Construction.
0307..........................  Myocardial Positron Emission Tomography
                                 (PET) Imaging.
0312..........................  Radioelement Applications.
0323..........................  Extended Individual Psychotherapy.
0330..........................  Dental Procedures.
0340..........................  Minor Ancillary Procedures.
0367..........................  Level I Pulmonary Test.
0381..........................  Single Allergy Tests.
0397..........................  Vascular Imaging.
0409..........................  Red Blood Cell Tests.
0418..........................  Insertion of Left Ventricular Pacing
                                 Elect.
0432..........................  Health and Behavior Services.
0437..........................  Level II Drug Administration.
0604..........................  Level I Clinic Visits.
0621..........................  Level I Vascular Access Procedures.
0664..........................  Level I Proton Beam Radiation Therapy.
0676..........................  Thrombolysis and Thrombectomy.
------------------------------------------------------------------------

C. New Technology APCs

1. Introduction
    In the November 30, 2001 final rule (66 FR 59903), we finalized 
changes to the time period a service was eligible for payment under a 
New Technology APC. Beginning in CY 2002, we retain services within New 
Technology APC groups until we gather sufficient claims data to enable 
us to assign the service to a clinically appropriate APC. This policy 
allows us to move a service from a New Technology APC in less than 2 
years if sufficient data are available. It also allows us to retain a 
service in a New Technology APC for more than 3 years if sufficient 
data upon which to base a decision for reassignment have not been 
collected. More recently, at its August 2006 meeting the APC Panel 
recommended that when CMS assigns a new service to a New Technology 
APC, the service should remain there for at

[[Page 68020]]

least 2 years until sufficient claims data are collected. In general, 
services remain in New Technology APCs for at least 2 years consistent 
with the APC Panel's recommendation. However, we do not fully accept 
the APC Panel's recommendation. While we agree with the APC Panel that 
we need sufficient claims data to move services from New Technology 
APCs to clinical APCs, we also continue to believe that it occasionally 
may be appropriate to move a service from a New Technology APC to a 
clinical APC in less than 2 years if the data are robust and there is 
an appropriate clinical APC for its assignment.
    We note that the cost bands for New Technology APCs range from $0 
to $50 in increments of $10, from $50 to $100 in increments of $50, 
from $100 through $2,000 in intervals of $100, and from $2,000 through 
$6,000 in intervals of $500. These intervals, which are in two parallel 
sets of New Technology APCs, one with status indicator ``S'' and the 
other with status indicator ``T,'' allow us to price new technology 
services more appropriately and consistently.
    Every year we receive many requests for higher payment amounts for 
specific procedures under the OPPS because they require the use of 
expensive equipment. We are taking this opportunity to reiterate our 
response in general to the issue of hospitals' capital expenditures as 
they relate to the OPPS and Medicare.
    Under the OPPS, one of our goals is to make payments that are 
appropriate for the services that are necessary for the treatment of 
Medicare beneficiaries. The OPPS, like other Medicare payment systems, 
is budget neutral and so, although we do not pay full hospital costs 
for procedures, we believe that our payment rates generally reflect the 
costs that are associated with providing care to Medicare beneficiaries 
in cost-efficient settings. Further, we believe that our rates are 
adequate to assure access to services for most beneficiaries.
    For many emerging technologies there is a transitional period 
during which utilization may be low, often because providers are first 
learning about the techniques and their clinical utility. Quite often, 
the requests for higher payment amounts are for new procedures in that 
transitional phase. These requests, and their accompanying estimates 
for expected Medicare beneficiary or total patient utilization, often 
reflect very low rates of patient use, resulting in high per use costs 
for which requesters believe Medicare should make full payment. 
Medicare does not, and we believe should not, assume responsibility for 
more than its share of the costs of procedures based on Medicare 
beneficiary projected utilization and does not set its payment rates 
based on initial projections of low utilization for services that 
require expensive capital equipment. For the OPPS, we rely on hospitals 
to make informed business decisions regarding the acquisition of high 
cost capital equipment, taking into consideration their knowledge about 
their entire patient base (Medicare beneficiaries included) and an 
understanding of Medicare's and other payers' payment policies.
    We note that in a budget neutral environment, payments may not 
fully cover hospitals' costs, including those for the purchase and 
maintenance of capital equipment. We rely on providers to make their 
decisions regarding the acquisition of high cost equipment with the 
understanding that the Medicare program must be careful to establish 
its initial payment rates for new services that lack hospital claims 
data based on realistic utilization projections for all such services 
delivered in cost-efficient hospital outpatient settings. As the OPPS 
acquires claims data regarding hospital costs associated with new 
procedures, we will regularly examine the claims data and any available 
new information regarding the clinical aspects of new procedures to 
confirm that our OPPS payments remain appropriate for procedures as 
they transition into mainstream medical practice.
2. Movement of Procedures From New Technology APCs to Clinical APCs
    As we explained in the November 30, 2001 final rule (66 FR 59897), 
we generally keep a procedure in the New Technology APC to which it is 
initially assigned until we have collected data sufficient to enable us 
to move the procedure to a clinically appropriate APC. However, in 
cases where we find that our original New Technology APC assignment was 
based on inaccurate or inadequate information, or where the New 
Technology APCs are restructured, we may, based on more recent resource 
utilization information (including claims data) or the availability of 
refined New Technology APC bands, reassign the procedure or service to 
a different New Technology APC that most appropriately reflects its 
cost.
    The procedures presented below represent services assigned to New 
Technology APCs for CY 2006 for which at the time of developing the 
proposed rule we believed we had sufficient data to reassign them to 
clinically appropriate APCs for CY 2007.
a. Nonmyocardial Positron Emission Tomography (PET) Scans (APC 0308)
    Positron emission tomography (PET) is a noninvasive diagnostic 
imaging procedure that assesses the level of metabolic activity and 
perfusion in various organ systems of the human body. PET serves an 
important role in the clinical care of many Medicare beneficiaries. We 
recognize that PET is a useful technology in many instances and want to 
ensure that the technology remains available to Medicare beneficiaries 
when medically necessary. Since August 2000, nonmyocardial PET 
procedures have been assigned to a New Technology APC in the OPPS. As a 
result of our collection of 5 full years of hospital claims data, in 
the CY 2007 proposed rule (71 FR 49566 through 49567) we indicated that 
we believed that we had sufficient data to assign nonmyocardial PET 
scans to a clinically appropriate APC for CY 2007. We assign a service 
to a New Technology APC only when we do not have adequate claims data 
upon which to determine the median cost of performing the procedure, 
and we expect that the service's clinical or resource characteristics 
will differ from all other procedures already assigned to clinical 
APCs. Each New Technology APC represents a particular cost band (for 
example, $1,400-1,500), and we assign procedures to these APCs based on 
our analysis of the costs of the procedures. Payment for items assigned 
to a New Technology APC is the midpoint of the band (for example, 
$1,450). We move a service from a New Technology APC to a clinical APC 
when we have adequate claims data upon which to base its future payment 
rate. As noted in the CY 2007 proposed rule, in the case of 
nonmyocardial PET services, we believed that we had sufficient data to 
assign them to a clinically appropriate APC.
    For CY 2006, we maintained the APC payment methodologies from CY 
2005 for nonmyocardial PET services. According to that methodology, 
payment was based on a 50/50 blend of their median cost based on CY 
2003 claims data and the payment rate of the CY 2004 New Technology APC 
to which they were assigned. Therefore, nonmyocardial PET scans were 
assigned to New Technology APC 1513 (New Technology--Level XIII ($1100-
$1200)) for a blended payment rate of $1,150.
    For CY 2007, we proposed the assignment of nonmyocardial PET 
procedures to a clinically appropriate APC as we now have several years 
of robust and stable claims data upon which to determine the median 
cost of

[[Page 68021]]

performing these procedures. Based on analysis of the Medicare claims 
data, the median costs for nonmyocardial PET scans have ranged between 
approximately $852 and $924 for claims submitted from CY 2002 through 
CY 2005. However, our payment rates have been significantly higher than 
the median costs throughout this same time period. We have observed 
significant growth in the number of nonmyocardial PET scans performed 
on Medicare beneficiaries, from about 48,000 in CY 2002, to 68,000 in 
CY 2003, and to 121,000 in CY 2004, the year when we first reduced the 
OPPS nonmyocardial PET scan payment rates from $1,450 to $1,150. For 
the CY 2007 OPPS proposed rule, we had about 45,000 single PET claims 
from CY 2005, yielding a stable median cost for PET procedures of about 
$867. Although the CY 2005 claims data were not complete when we 
published the CY 2007 OPPS proposed rule, we noted that the apparent 
decline in numbers of claims for nonmyocardial PET scans alone in the 
CY 2005 claims data was likely related to the large number of claims 
for PET/CT scans observed in CY 2005, when codes for that combined 
service were first available for billing. In fact, the total number of 
PET scans provided to Medicare beneficiaries in CY 2005, defined as PET 
scans and PET/CT scans, continued to climb to almost 128,000 based upon 
the CY 2005 claims data available for the proposed rule, in comparison 
to final claims for CY 2004 of approximately 121,000 for PET scans.
    Therefore, we proposed to assign nonmyocardial PET scans, in 
particular, CPT codes 78608, 78811, 78812, and 78813, to new APC 0308 
(Nonmyocardial Positron Emission Tomography (PET) Imaging) with a 
median cost of $865.30 for CY 2007. We noted we were confident that in 
the face of our stable median costs for nonmyocardial PET scans over 
the past 4 years, their additional 2-year period of receiving New 
Technology APC payments at the blended rate of $1,150 for CY 2005 and 
CY 2006 as we transitioned the services to a clinical APC would ensure 
continued availability of this technology now that its services would 
be paid through a clinical APC in CY 2007, like most other OPPS 
services.
    Comment: A few commenters representing rural providers stated that 
they would no longer be able to provide PET scans to their patients who 
are Medicare beneficiaries if Medicare lowered its payment for the 
services. They stated that, because they relied on more costly, mobile 
units, the proposed payment amount would not be adequate for them to be 
able to continue to provide the service in their communities. A number 
of other commenters opposed proposed payment reductions for PET imaging 
services that they believed were essential to ensuring appropriate 
treatment of patients with cancer and providing necessary patient 
access.
    Response: We are sensitive to the obstacles that rural providers 
face in trying to provide some services to Medicare beneficiaries. 
However, we have years of stable and consistent data that indicate that 
Medicare will now be paying more accurately for the scans at the 
proposed clinical APC rate. We believe this rate will ensure the 
necessary patient access to PET services.
    Comment: Several commenters requested that, instead of assigning 
CPT code 78608 (Brain imaging, positron emission tomography (PET); 
metabolic evaluation), to APC 0308 with the CPT codes for tumor PET 
scans, CMS should assign this single code to a separate clinical APC. 
The commenters had no objections to assignment of PET services to 
clinical APCs, with payment rates based on the APCs' median costs. The 
commenters believed that assignment of the CPT code for brain PET scans 
to its own APC would be more appropriate because the brain PET scans 
are not clinically homogenous with the other tumor PET scans assigned 
to APC 0308.
    Response: The brain PET scan services have been assigned to the 
same New Technology APC with the same payment rate as the other 
nonmyocardial PET services for a number of years. The CY 2005 median 
cost for the brain PET CPT code of $886 is very similar to the median 
costs for the two tumor PET CPT codes of $873 and $762, indicating that 
all three of these related PET services require comparable hospital 
resources. We are not convinced that separating nonmyocardial PET scans 
according to the body site being examined is necessary for clinical 
homogeneity, and the result of such a distinction would be a single CPT 
code in one APC and two CPT codes in another APC. The OPPS is a 
prospective payment system that provides payment for groups of services 
that share clinical and resource use characteristics. We believe that 
PET scans for tumor imaging and brain imaging are similar in both 
respects and are appropriately assigned to the same clinical APC. 
Therefore, we are finalizing our proposal to assign CPT code 78608 to 
APC 0308, along with CPT codes 78811, 78812, and 78813.
    After carefully considering the comments, we are adopting our 
proposal for CY 2007 without modification to provide payment for 
nonmyocardial PET scans through APC 0308.
b. PET/Computed Tomography (CT) Scans (APC 0308)
    Since August 2000, we have paid separately for PET and CT scans. In 
CY 2004, the payment rate for nonmyocardial PET scans was $1,450, while 
it was $193 for typical diagnostic CT scans. Prior to CY 2005, 
nonmyocardial PET and the PET portion of PET/CT scans were described by 
G-codes for billing to Medicare. Several commenters on the November 15, 
2004 final rule with comment period (69 FR 65682) urged us to replace 
the G-codes for nonmyocardial PET and PET/CT scan procedures with the 
established CPT codes. These commenters stated that movement to the 
established CPT codes would greatly reduce the burden on hospitals of 
tracking and billing the G-codes that were not recognized by other 
payers and would allow for more uniform hospital billing of these 
scans. We agreed with the commenters that movement from the G-codes to 
the established CPT codes for nonmyocardial PET and PET/CT scans would 
allow for more uniform billing of these scans. As a result of a 
Medicare national coverage determination (Publication 100-3, Medicare 
Claims Processing Manual section 220.6) that was made effective January 
28, 2005, we discontinued numerous G-codes that described myocardial 
PET and nonmyocardial PET procedures and replaced them with the 
established CPT codes. The CY 2005 payment rate for concurrent PET/CT 
scans using CPT codes 78814, 78815, and 78816 was $1,250, which was 
$100 higher than the payment rate for PET scans alone. These PET/CT CPT 
codes were placed in New Technology APC 1514 (New Technology--Level XIV 
($1,200-$1,300)) for CY 2005. We continued with these coding and 
payment methodologies in CY 2006.
    For CY 2007, we proposed the assignment of concurrent PET/CT scans, 
specifically CPT codes 78814, 78815, and 78816, to a clinically 
appropriate APC because we believed that we had adequate claims data 
from CY 2005 upon which to determine the median cost of performing 
these procedures. At the time of the proposed rule, based on our 
analysis of CY 2005 single claims, the median cost of PET/CT scans was 
$865 from almost 70,000 single claims. Comparison of the median cost of 
nonmyocardial PET procedures of $867 with the median cost of concurrent 
PET/CT scans demonstrated that the median costs of PET scans with or 
without

[[Page 68022]]

concurrent CT scans for attenuation correction and anatomical 
localization were about the same. This result was not unexpected 
because many newer PET scanners also had the capability of rapidly 
acquiring CT images for attenuation correction and anatomical 
localization, sometimes with simultaneous image acquisition.
    To explore the possibility that the similarity in median costs for 
PET and PET/CT procedures could be related to different groups of 
hospitals billing the two types of PET services based on their 
available equipment, rather than the true comparability of hospital 
resources required for the two types of services, we analyzed claims 
from a subset of hospitals billing both PET and PET/CT scans in CY 
2005. This analysis looked at 362 providers that billed a PET HCPCS 
code and a PET/CT CPT code at least one time each during CY 2005. The 
median cost from this subset of claims for nonmyocardial PET scans was 
$890, in comparison with $863 for the PET/CT scans. Thus, we observed 
the same close relationship between median costs of PET and PET/CT 
procedures from hospitals billing both sets of services as we did for 
all OPPS CY 2005 claims available for the proposed rule for these 
scans. We believed that our claims data accurately reflected the 
comparable hospital resources required to provide PET and PET/CT 
procedures, and the scans had obvious clinical similarity as well. 
Therefore, for CY 2007 we proposed to assign the CPT codes for PET/CT 
scans, along with the CPT codes for PET scans, to the same new APC 0308 
(Nonmyocardial Positron Emission Tomography (PET) Imaging) with a 
proposed median cost of $865.30.
    At its August 2006 meeting, the APC Panel recommended that CMS 
retain PET/CT scans in New Technology APC 1514 with a payment rate of 
$1,250 for CY 2007.
    We note that we have been paying separately for fluorodeoxyglucose 
(FDG), the radiopharmaceutical described by HCPCS code A9552 
(Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 
millicuries) that is commonly administered during nonmyocardial PET and 
PET/CT procedures. For CY 2007, we proposed to continue paying 
separately for FDG, according to the methodology described in section 
V. of the preamble of the CY 2007 proposed rule.
    Comment: A number of commenters disagreed with the proposal to 
assign PET/CT services to APC 0308. Among the reasons provided by 
commenters that PET/CT services should not be assigned to APC 0308 were 
that: payment at the proposed level would not cover the costs of 
providing the services; the APC Panel recommended during its August 
2006 meeting that CMS retain PET/CT services in New Technology APC 1514 
for another year so that more CPT-coded claims upon which to base a 
decision about the appropriate APC assignment for the services would be 
available; PET/CT services are a clinically distinct technology from 
conventional PET procedures and should not be assigned to the same APC; 
PET/CT services are more costly to provide than are other nonmyocardial 
PET services and there must be a payment differential to recognize 
that; and a 30-percent payment decrease would result in decreased 
Medicare beneficiary access to the services. The commenters reported 
that the higher costs associated with PET/CT were due to requirements 
for specially-trained, licensed technicians, more costly capital 
equipment, and higher equipment maintenance costs.
    Most commenters recommended that PET/CT should remain in its 
current New Technology APC 1514 with a payment rate of $1,250 for CY 
2007. Some of the commenters believed that CMS' proposal to assign PET/
CT scans to a clinical APC was premature because CMS did not have a 
full year of reliable cost data for PET/CT. They made that assertion 
because the CPT codes used to report the services were newly recognized 
by the OPPS in April 2005 and, therefore, only 9 months of claims data 
were available for the CY 2007 OPPS update. The commenters observed 
that if PET/CT scans were moved to a clinical APC for CY 2007, they 
would have been assigned to a New Technology APC for only 21 months, 
while the APC Panel recommended at its August 2006 meeting that 
services assigned to New Technology APCs should remain there for at 
least 2 years. Further, because hospitals often do not update their 
chargemasters more than once per year, the commenters believed that 
true hospital costs were not reflected in the CY 2005 data that CMS 
considered when developing its proposal for CY 2007.
    One of the commenters provided limited hospital-level average cost 
data for PET and PET/CT scans, as well as a cost analysis model for 
PET/CT services. Those data covered the 6-month period of July through 
December and display average cost and charge data for two sets of 
hospitals, separated according to two different methods of reducing 
their charges to costs.
    Response: We have carefully considered the APC Panel recommendation 
and all of the information provided in the comments received regarding 
the proposed APC assignment and payment amount for PET/CT scans for CY 
2007. We remain confident that our CY 2005 data for conventional 
nonmyocardial PET services are accurate reflections of hospital costs 
for those services, in spite of the CY 2005 coding changes. Similarly, 
our review of the hospital data provided in one of the public comments 
shows that the average cost per hospital for PET/CT for one set of 
hospitals was $829 and for the other group was $912. We are encouraged 
that these mean costs are so similar to our median cost for the 
services, and these data serve to increase our confidence in the CY 
2005 claims data.
    However, we recognize that there are other factors to consider 
related to hospital charging practices for PET/CT services. For 
instance, prior to institution of the specific CPT codes for PET/CT 
scans, hospitals were reporting a diagnostic CT scan charge in addition 
to the appropriate G-code charge for the PET scan. Therefore, the 
transition to the new CPT codes was not a simple coding crosswalk for 
the PET/CT services because it required the hospital to change from 
reporting two charges for the service to only one charge that was to 
include the costs of the entire service. We are aware that making that 
adjustment may have been difficult for some hospitals.
    After considering the information and opinions provided to us in 
the comments, particularly with respect to our data that are limited to 
9 months of claims (although there are over 76,000 single claims from 
that time period), we are persuaded that there are valid reasons to 
assign PET/CT services to a different APC than the conventional PET 
services for CY 2007. We are convinced that, in this instance, we 
should wait for a full year of CPT-coded claims data prior to assigning 
the PET/CT services to a clinical APC and that maintaining a modest 
payment differential between PET and PET/CT procedures is warranted for 
CY 2007.
    For these reasons, we are assigning PET/CT to a different APC than 
conventional PET services for CY 2007, based on our continued 
expectation of the appropriate relative cost difference between the two 
types of services. When we first recognized PET/CT CPT codes for 
payment in CY 2005, we established their payment rate at $100 more than 
the payment rate for PET scans. Although the commenters to the CY 2007 
proposed rule did not provide specific information regarding an 
appropriate differential between

[[Page 68023]]

payments for PET and PET/CT scans, the commenters generally did not 
oppose our proposed payment for PET scans through a clinical APC with a 
payment rate of about $850. Historically, when both PET and PET/CT 
scans were assigned to New Technology APCs with a $100 payment 
difference for CYs 2005 and 2006, we received few public comments 
indicating that payment difference was inappropriate. Therefore, we are 
assigning PET/CT scans to New Technology APC 1511 (New Technology--
Level XI ($900-$1,000)) with a payment of $950 for CY 2007 to maintain 
the approximately $100 difference between payments these services and 
nonmyocardial PET scans, which will be assigned to APC 0308 with a 
median cost of about $850 for CY 2007. In this way, the differential 
payment between conventional PET and PET/CT scans will be preserved at 
an appropriate level, the payment decrease for PET/CT procedures will 
be moderated as the services transition to payment based on their costs 
in a clinical APC, and CMS will be able to consider a full 12 months of 
CPT-coded claims prior to making the assignment of PET/CT scans to a 
clinical APC.
c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 
0065, 0066, and 0067)
    For the past several years, we have collected hospital costs 
associated with the planning and delivery of stereotactic radiosurgery 
services (hereafter referred to as SRS). As new technology emerged in 
the field of SRS, public commenters urged us to recognize cost 
differences associated with the various methods of SRS planning and 
delivery. Beginning in CY 2001, we established G-codes to capture any 
such cost variations associated with the various methods of planning 
and delivery of SRS. For CY 2004, based on comments received regarding 
the G-codes used for SRS, we made some modifications to the coding (68 
FR 63431 and 63432). First, we received comments regarding the 
descriptors for HCPCS codes G0173 and G0251, indicating that these 
codes did not distinguish image-guided robotic SRS systems from other 
forms of linear accelerator-based SRS systems to account for the cost 
variation in delivering these services. In response, for CY 2004 we 
created two new G-codes (G0339 and G0340) to describe complete and 
fractionated image-guided robotic linear accelerator-based SRS 
treatment. We placed HCPCS code G0339 in APC 1528 at a payment rate of 
$5,250, and HCPCS code G0340 in APC 1525 at a payment rate of $3,750. 
Second, we received comments on HCPCS code G0242 which requested that 
we modify the code descriptor to avoid confusion and misuse of the 
code, and also to appropriately describe treatment planning for both 
linear accelerator-based and Cobalt 60-based SRS treatments. In 
response, for CY 2004, we created HCPCS code G0338 to distinguish 
linear accelerator-based SRS treatment planning from Cobalt 60-based 
SRS treatment planning. We placed HCPCS code G0338 in APC 1516 at a 
payment rate of $1,450.
    In CY 2005, there were no changes to the coding or New Technology 
APC payment rates for the SRS planning or treatment delivery codes from 
CY 2004. We stated in the CY 2005 OPPS final rule with comment period 
(69 FR 65711) that any SRS code changes would be premature without cost 
data to support a code restructuring. Therefore, we maintained HCPCS 
codes G0173, G0242, G0243, G0251, G0338, G0339, and G0340 in their 
respective New Technology APCs for CY 2005. We further stated that 
until we had completed an analysis of claims for these procedure codes, 
we would continue to maintain HCPCS codes G0173, G0242, G0243, G0251, 
G0338, G0339, and G0340 in their respective New Technology APCs for CY 
2005 as we considered the adoption of CPT codes to describe all SRS 
procedures for CY 2006.
    At its February 2005 meeting, the APC Panel discussed the clinical 
and resource cost similarities between planning for Cobalt 60-based and 
linear accelerator-based SRS. The APC Panel also discussed the use of 
CPT codes instead of specific G-codes to describe the services involved 
in SRS planning, noting the clinical similarities in radiation 
treatment planning regardless of the mode of treatment delivery. Given 
the APC Panel's deliberations about the possible need for CMS to 
separately track planning for SRS, the APC Panel eventually recommended 
that CMS create a single HCPCS code to encompass both Cobalt 60-based 
and linear accelerator-based SRS planning. Because we had no 
programmatic need to separately track SRS planning services, in the CY 
2006 OPPS final rule with comment period (70 FR 68585), we discontinued 
HCPCS codes G0242 and G0338 for the reporting of charges for SRS 
planning and instructed hospitals to bill charges for SRS planning, 
regardless of the mode of treatment delivery, using all of the 
available CPT codes that most accurately reflect the services provided.
    Furthermore, the APC Panel recommended that CMS make no changes to 
the coding or APC placement of SRS treatment delivery HCPCS codes 
G0173, G0243, G0251, G0339, and G0340 for CY 2006. In addition, 
presenters to the APC Panel described ongoing deliberations among 
interested professional societies around the descriptions and coding 
for SRS. The APC Panel and presenters suggested that CMS wait for the 
outcome of these deliberations before making any significant changes to 
SRS delivery coding or payment rates. As indicated in the CY 2007 OPPS 
proposed rule, we did not receive a report from participating 
professional societies as to the outcome of such deliberations prior to 
publishing that rule (71 FR 49554).
    In response to comments for CY 2006 regarding the mature technology 
and stable median costs associated with Cobalt 60-based SRS treatment 
delivery described by HCPCS code G0243, we reassigned G0243 from a New 
Technology APC to new clinical APC 0127 (Stereotactic Radiosurgery), 
with a payment rate of $7,305 established based on the CY 2004 median 
cost of G0243. We made no changes for CY 2006 to the New Technology APC 
assignments of the other four SRS treatment codes, specifically, G0173, 
G0251, G0339, and G0340.
    Since we first established the full group of SRS treatment delivery 
codes in CY 2004, we now have 2 years of hospital claims data 
reflecting the costs of each of these services. Based on our proposed 
rule analysis of our claims data from CY 2004 and CY 2005, the median 
costs for linear accelerator-based SRS treatment delivery procedures as 
described by HCPCS codes G0173, G0251, G0339, and G0340 have been 
stable and generally lower than our New Technology APC payment rates in 
effect from CY 2004 through CY 2006. Specifically, the payment rate for 
HCPCS code G0173, a complete course of non-image guided, non-robotic 
linear accelerator-based SRS treatment, has been set at $5,250, yet our 
claims data indicate a median cost of $2,802 from CY 2004 claims and 
$3,665 from our proposed rule CY 2005 claims, based upon hundreds of 
single claims from each year. For HCPCS code G0251, fractionated non-
image guided, non-robotic linear accelerator-based SRS treatment, the 
corresponding median costs have been $1,028 and $1,386 based upon over 
1,000 single claims from each year, and relatively consistent with the 
procedure's New Technology APC payment of $1,150. With respect to the 
complete course of therapy in one session or first fraction of image-
guided, robotic linear accelerator-based SRS, described by HCPCS code 
G0339, its

[[Page 68024]]

median costs have been $4,917 and $4,809 for CY 2004 and CY 2005 
respectively, based upon over 500 single bills in each year, in 
comparison with the procedure's payment rate of $5,250 for those years. 
Lastly, the median costs of HCPCS code G0340, the second through fifth 
sessions of image-guided, robotic linear accelerator-based SRS 
treatment, have been $2,502 for CY 2004 and $2,917 for CY 2005 as 
determined by over 1,000 single bills during each year, significantly 
lower than its payment rate of $3,750. Unquestionably, the claims data 
from CY 2004 and CY 2005 for linear accelerator-based SRS treatment 
delivery services revealed highly stable median costs from year to year 
based on significant claims volume.
    Based on the above findings, in the CY 2007 proposed rule we 
indicated that we believed that we had adequate claims data to assign 
the SRS treatment delivery procedures to clinically appropriate APCs, 
and we believed that such movement was appropriate. For CY 2007, we 
proposed to create several new SRS clinical APCs of different levels to 
assign the HCPCS codes describing linear accelerator-based SRS 
treatment, G0173, G0251, G0339, and G0340, based on their clinical and 
hospital resource similarities and differences. In particular, we 
proposed to assign HCPCS codes G0339 and G0173 to the same Level III 
SRS APC, because we believed that these codes that describe the 
complete or first fraction of all types of linear accelerator-based SRS 
treatments had substantial hospital resource and clinical similarity, 
as observed in their median costs and recognized previously in their 
equivalent New Technology APC payments. The codes describing subsequent 
fractions of image-guided, robotic and non-image guided, non-robotic 
linear accelerator-based SRS treatments were each assigned to their own 
clinical APCs in our proposal, as they demonstrated significant 
differences in resource utilization as reflected in their median costs. 
Their previous assignments to different New Technology APCs anticipated 
these resource distinctions. We proposed to continue our assignment of 
HCPCS code G0243 for Cobalt 60-based SRS treatment delivery to clinical 
APC 0127, renamed Level IV Stereotactic Radiosurgery. Our proposed 
reassignments of SRS services from New Technology APCs to clinical APCs 
were listed in Table 8 of the CY 2007 OPPS proposed rule (71 FR 49554), 
which has been reproduced as Table 8 below, amended with the final 
status indicators, APC assignments, and median costs for these 
services.
    We received many comments on our proposal from hospitals, health 
professionals, and various healthcare associations. A summary of the 
comments and our responses follow:
    Comment: Several commenters objected to our use of the CY 2005 
claims data in setting the CY 2007 payment rates, specifically with 
regards to the image-guided robotic SRS services, as described by HCPCS 
codes G0339 and G0340. They indicated that the claims data used to set 
the proposed payment rates for HCPCS codes G0339 and G0340 were based 
on a flawed methodology because several centers providing these 
services submitted claims to CMS for less than a full year during CY 
2004 and CY 2005. Because centers that provided image-guided SRS grew 
in number significantly over the past 2 years, the commenters believed 
that CMS did not have meaningful data over 2 years from a large number 
of institutions providing the services upon which to base the proposed 
changes. They believed that new technology services should have a 
minimum of 2 years of claims data before moving them to clinical APCs. 
These commenters urged CMS to maintain HCPCS code G0339 in its current 
New Technology APC 1528 with a payment rate of $5,250, and to also 
maintain HCPCS G0340 in its current New Technology APC 1525 with a 
payment rate of $3,750.
    Response: In the November 30, 2001 final rule (66 FR 59903), we 
finalized changes to the time period a service was eligible for payment 
under a New Technology APC. Beginning in CY 2002, we noted that we 
would retain services within New Technology APC groups until we 
gathered sufficient claims data to enable us to assign the service to a 
clinically appropriate APC. There is no requirement for a minimum 
number of claims or years of claims data before services may be moved 
from New Technology APCs to clinical APCs.
    In the case of the image-guided robotic SRS services, specifically 
G0339 and G0340, we continue to believe that we have adequate claims 
data from CY 2005 upon which to base our payments for CY 2007. Both 
HCPCS codes G0339 and G0340 were effective for reporting beginning 
January 1, 2004, under the OPPS, and consequently, we have 2 full years 
worth of hospital claims data for these services. As we noted earlier, 
the median costs for both procedures have been reasonably stable over 
the past 2 years based upon substantial numbers of single claims, and 
there was similar growth in both services from CY 2004 to CY 2005. The 
fact that image-guided robotic SRS centers have grown in number and 
service volume over the most recent 2 years of claims submissions is 
expected for new technology and other OPPS services. Many OPPS services 
are only provided in a small subset of hospitals paid under the OPPS, 
and we routinely establish APC median costs based on Medicare OPPS 
claims from the hospitals that were providing the services 2 years 
prior to the OPPS update year. We recognize that our claims data evolve 
over time, in part because the pool of hospitals providing certain 
procedures may change significantly.
    The information provided in the comments did not convince us that 
the proposed payment rates for HCPCS code G0339 and G0340 were based on 
inadequate claims data that did not represent the costs of the 
procedures for the hospitals providing the services in CY 2005. Based 
on our final CY 2005 claims data, we found 1,535 single (of 1,655 
total) claims for HCPCS code G0339 and 2,716 single (of 2,798 total) 
claims for HCPCS code G0340. We believe that the single claims data for 
both procedures are sufficiently robust for ratesetting purposes.
    Comment: Several commenters agreed with CMS that the hospital 
claims data from the past 2 years for the SRS services have been 
relatively stable and based on at least several hundreds of claims both 
years. However, these commenters expressed concern about our proposal 
to assign HCPCS codes G0173 and G0339 to the same APC, specifically APC 
0067 (Level III Stereotactic Radiosurgery). The commenters opposed 
assignment of the two procedures to the same APC because they believed 
that our claims data clearly showed that the median cost of G0339 has 
been significantly higher than the median cost of G0173 for both CY 
2004 and CY 2005.
    Response: Both services have been assigned to the same New 
Technology APC 1528 for the past 3 years because of our initial 
expectation that the costs of the first or complete session of linear 
accelerator-based SRS would be similar, regardless of whether or not 
the SRS procedure was an image-guided robotic service. While we have 
observed that their costs are somewhat different, we believe that they 
are sufficiently comparable to warrant placement of the SRS services in 
the same clinical APC, given the comparable clinical characteristics of 
the services. The OPPS provides payments based on APC groups of 
services that share clinical and resource characteristics, and the 
median of the highest cost service

[[Page 68025]]

within an APC group should not be more than 2 times greater than the 
median cost of the lowest cost service within that same group. The 
final CY 2005 median cost of G0173 is $3,407.53, and the final CY 2005 
median cost of G0339 is $4,126.46. These median costs are quite 
comparable, and APC 0067, configured as proposed, does not violate the 
2 times limit on the variation of costs within the APC.
    Therefore, for CY 2007, both HCPCS codes G0339 and G0173 are 
reassigned to clinical APC 0067 with a median cost of $3,872.87, and 
HCPCS code G0340 is reassigned to clinical APC 0066, with a median cost 
of $2,629.53.
    Comment: Several organizations supported our proposed clinical APC 
assignments but were concerned by the extent of the payment reductions 
for certain services. The commenters expressed concern regarding the 
23-percent reduction in payment for HCPCS codes G0173 and G0339. They 
urged CMS to review the cost calculations for all SRS services and use 
the most current claims data available for the CY 2007 OPPS final rule.
    Response: We thank the commenters for their suggestion. The payment 
rates reflected in Table 8 are based on the latest and most complete CY 
2005 claims data, with CY 2007 payment rates based upon APC median 
costs calculated according to the standard OPPS methodology. Almost all 
of the claims are single claims; therefore, we are confident that the 
observed costs in the claims data are representative of the costs of 
the SRS services provided in CY 2005.
    Comment: Several commenters requested that CMS modify the 
descriptors for HCPCS codes G0339 and G0340 to be more precise and 
reflect the technology accurately. The commenters provided their 
proposed language, and indicated that not refining the descriptors 
would make it virtually impossible to determine appropriate APC payment 
rates for image-guided robotic SRS services in the future. They also 
urged CMS to work with the centers providing these specialized services 
to establish accurate and appropriate payments for image-guided robotic 
SRS.
    Response: The recommended language provided by the commenters is 
very specific and may cause more confusion for hospitals and coders. 
Long descriptors of HCPCS codes that describe services and procedures 
are usually more general and not specific to a particular specialty or 
product. We do not establish HCPCS codes that are specific to certain 
technologies. Instead, we rely on hospitals to select the most specific 
HCPCS codes that accurately describe the services they provide. We 
believe that the current HCPCS code descriptors adequately distinguish 
image-guided robotic linear accelerator-based SRS from other types of 
SRS. We observe significant difference in the costs of G0251 and G0340 
that describe the later fractions of non-image-guided and image-guided 
SRS respectively, so that they require assignment to two separate 
clinical APCs. We have no evidence that hospitals are not accurately 
reporting these services based on the technology utilized to provide 
SRS in their institutions.
    For CY 2007, the CPT Editorial Panel created four new SRS Category 
I CPT codes in the Radiation Therapy section of the 2007 CPT manual. 
Specifically, the CPT Editorial Panel created CPT codes 77371 
(Radiation treatment delivery, stereotactic radiosurgery (SRS) 
(complete course of treatment of cerebral lesion[s] consisting of 1 
session); multi-source Cobalt 60 based)), 77372 (Radiation treatment 
delivery, stereotactic radiosurgery (SRS) (complete course of treatment 
of cerebral lesion[s] consisting of 1 session); linear accelerator 
based)), 77373 (Stereotactic body radiation therapy, treatment 
delivery, per fraction to 1 or more lesions, including image guidance, 
entire course not to exceed 5 fractions), and 77435 (Stereotactic body 
radiation therapy, treatment management, per treatment course, to one 
or more lesions, including image guidance, entire course not to exceed 
5 fractions). For CY 2007, we will continue our recent practice of not 
recognizing established CPT code 61793 (Stereotactic radiosurgery 
(particle beam, gamma ray or linear accelerator), one or more sessions) 
under the OPPS because the OPPS will utilize more specific SRS codes to 
provide appropriate payment for the facility resources associated with 
specific types of SRS treatment delivery. Below is our discussion of 
the new SRS CPT codes, and our assignments for the codes under the 
OPPS.
     CPT code 77371 describes a cobalt-based SRS procedure for 
a single, complete treatment session of one or more cerebral lesions. 
Under the OPPS, this procedure has been separately payable under HCPCS 
code G0243 (Multi-source photon stereotactic radiosurgery, delivery 
including collimator changes and custom plugging, complete course of 
treatment, all lesions) since January 1, 2002. We believe this single 
CPT code may be appropriately reported in all clinical situations of 
cobalt-based SRS treatment. For CY 2007, HCPCS G0243 will no longer be 
reportable under the hospital OPPS because the code will be deleted and 
replaced with CPT code 77371, effective January 1, 2007. CPT code 77371 
is assigned to the same APC and status indicator as its predecessor 
code (G0243). That is, for CY 2007, CPT code 77371 is assigned to APC 
0127 (Level IV Stereotactic Radiosurgery) with a status indicator of 
``S''.
     CPT code 77372 describes a single session, complete course 
of treatment, linear accelerator-based procedure. During CY 2006, this 
procedure was reported under one of two HCPCS codes, depending on the 
technology used, specifically, G0173 (Linear accelerator based 
stereotactic radiosurgery, complete course of therapy in one session) 
and G0339 (Image-guided robotic linear accelerator-based stereotactic 
radiosurgery, complete course of therapy in one session or first 
session of fractionated treatment). Because HCPCS codes G0173 and G0339 
are more specific in their descriptors than CPT code 77372, we have 
decided to continue using G0173 and G0339 under the OPPS for CY 2007. 
Therefore, for CY 2007, we have assigned CPT code 77372 to status 
indicator ``B'' under the OPPS.
     CPT code 77373 describes a fractionated session linear 
accelerator-based procedure. During CY 2006, CPT code 77373 was 
reported under one of three HCPCS codes depending on the circumstances 
and technology used, specifically, G0251 (Linear accelerator-based 
stereotactic radiosurgery, delivery including collimator changes and 
custom plugging, fractionated treatment, all lesions, per session, 
maximum five sessions per course of treatment), G0339 (Image-guided 
robotic linear accelerator-based stereotactic radiosurgery, complete 
course of therapy in one session or first session of fractionated 
treatment), and G0340 (Image-guided robotic linear accelerator-based 
stereotactic radiosurgery, delivery including collimator changes and 
custom plugging, fractionated treatment, all lesions, per session, 
second through fifth sessions, maximum five sessions per course of 
treatment). Because HCPCS codes G0251, G0339, and G0340 are more 
specific in their descriptors than CPT code 77373 and these HCPCS codes 
are assigned to different clinical APCs for CY 2007, we have decided to 
continue using G0251, G0339, and G0340 under the OPPS for CY 2007. 
Therefore, for CY 2007, we have assigned CPT code 77373 to status 
indicator ``B'' the hospital OPPS.
     CPT code 77435 also describes treatment management for a 
full treatment course of linear accelerator-based SRS. During CY 2006, 
CPT code

[[Page 68026]]

77435 was described under CPT code 0083T (Stereotactic body radiation 
therapy, treatment management, per day), which was assigned to status 
indicator ``N'' in the OPPS. The CPT Editorial Panel has decided to 
delete CPT code 0083T on December 31, 2006, and replaced it with CPT 
code 77435. Because the costs of SRS treatment management are already 
packaged into the OPPS payment rates for SRS treatment delivery, for 
CY2007 we have assigned CPT code 77435 to status indicator ``N'', which 
is the same status indicator that was assigned to its predecessor 
Category III CPT code.
    After carefully considering all the comments and concerns raised by 
the commenters, we are finalizing our proposal as shown in Table 8 
without modification. Given the ample cost information reflected in the 
CY 2005 claims data for the SRS services and given the fact that these 
services have been in New Technology APCs for 3 full years, since they 
were first assigned to New Technology APCs beginning January 1, 2004, 
we believe our claims data are sufficient for us to move these services 
to clinical APCs. Therefore, for CY 2007, HCPCS codes G0173 and G0339 
are assigned to clinical APC 0067, with a median cost of $3,872.87, 
HCPCS code G0251 to clinical APC 0065, with a median cost of $1,241.89, 
and HCPCS code G0340 to clinical APC 0066 with a median cost of 
$2,629.53. As described above, despite new CPT codes for SRS treatment 
delivery in CY 2007, coding for linear accelerator-based SRS treatment 
delivery services will not change in the CY 2007 OPPS.

                                     Table 8.--Final APC Assignments for SRS Treatment Delivery Services for CY 2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                           Final CY 2007
    HCPCS code         Short descriptor          CY 2006 SI          CY 2006 APC       CY 2006        Final CY 2007 SI     Final CY 2007    APC median
                                                                                    payment rate                                APC            cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
G0173.............  Linear acc stereo      S.....................            1528       $5,250.00  S....................            0067       $3,872.87
                     radsur com.
G0251.............  Linear acc based       S.....................            1513        1,150.00  S....................            0065        1,241.89
                     stero radio.
G0339.............  Robot lin-radsurg      S.....................            1528        5,250.00  S....................            0067        3,872.87
                     com, first.
G0340.............  Robt lin-radsurg       S.....................            1525        3,750.00  S....................            0066        2,629.53
                     fractx 2-5.
--------------------------------------------------------------------------------------------------------------------------------------------------------

d. Magnetoencephalography (MEG) Services (APCs 0038 and 0209)
    Magnetoencephalography (MEG) is a noninvasive diagnostic tool that 
assists surgeons in the presurgical period by measuring and mapping 
brain activity. It may be used for epilepsy and brain tumor patients. 
Since CY 2002, the MEG procedures described by CPT codes 95965 
(Magnetoencephalography (MEG), recording and analysis; for spontaneous 
brain magnetic activity (eg, epileptic cerebral cortex localization)), 
95966 (Magnetoencephalography (MEG), recording and analysis; for evoked 
magnetic fields, single modality (e.g., sensory, motor, language, or 
visual cortex localization)), and 95967 (Magnetoencephalography (MEG), 
recording and analysis; for evoked magnetic fields, each additional 
modality (e.g., sensory, motor, language, or visual cortex 
localization)) have been assigned to New Technology APCs. In the CY 
2006 proposed rule (70 FR 42709), we proposed to reassign MEG 
procedures to clinical APC 0430 using CY 2004 claims data to establish 
median costs on which the CY 2006 payment rates would be based. This 
proposal involved the reassignment of the three MEG procedures, 
specifically CPT codes 95965, 95966, and 95967, from three separate New 
Technology APCs into one new clinical APC with a status indicator of 
``T.'' The commenters on the CY 2006 proposal believed that their 
assignment to clinical APC 0430 would be inappropriate because the 
proposed payment level of $674 was inadequate to cover the costs of the 
procedures, and because the procedures should not be assigned to only 
one level as their required hospital resources differ significantly. 
They further stated that our data did not represent the true costs of 
the procedures because MEG procedures are performed on very few 
Medicare patients.
    Analysis of our hospital data for claims submitted from CY 2002 
through CY 2005 indicated that these procedures are rarely performed on 
Medicare beneficiaries. For claims submitted from CY 2002 through CY 
2005, our single claims data showed that there were annually only 
between 2 and 23 claims submitted for CPT code 95965, between 3 and 7 
claims for CPT code 95966, and only 1 claim for CPT code 95967. In 
addition, the hospital claims median costs for these codes have varied 
widely, perhaps due to our small volume of claims. The median cost for 
CPT code 95965 has ranged from $332 using CY 2002 claims to $3,166 
based upon CY 2005 claims. The median cost for CPT code 95966 has 
varied widely from CY 2002 to CY 2005. For single claims submitted 
during CY 2002, the median cost was $1,949, while it was $507 for CY 
2003, $1,435 for CY 2004, and $701 from 3 single claims for CY 2005. 
The median cost for CPT code 95967 based upon 1 single claim from CY 
2005 claims was $217. As noted in our CY 2007 OPPS proposed rule (71 FR 
49555), we had no hospital median cost data for CPT code 95967 prior to 
CY 2005.
    In the November 10, 2005 final rule with comment period (70 FR 
68579), we stated that we carefully considered our claims data, 
information provided by the commenters, and the APC Panel 
recommendation for CY 2006 that we retain the MEG procedures in New 
Technology APCs. As a result of this analysis, we determined that using 
a 50/50 blend of the code-specific median costs from our most recent CY 
2004 hospital claims data and the CY 2005 New Technology APC code-
specific payment amounts as the basis for assignment of the procedures 
for CY 2006 would be an appropriate way to recognize both the current 
payment rates for the procedures, which were originally based on the 
theoretical costs to hospitals of providing MEG services, and the 
median costs based upon our hospital claims data regarding actual MEG 
services provided to Medicare beneficiaries by hospitals. Therefore, 
CPT codes 95965, 95966, and 95967 were assigned to different New 
Technology APCs for CY 2006 based on this blended methodology, with 
payment rates of $2,750, $1,250, and $850 respectively.
    At the March 2006 APC Panel meeting, the Panel recommended that CMS 
move CPT codes 95965 (MEG, spontaneous), 95966 (MEG, evoked, single), 
and 95967 (MEG, evoked, each additional) from their CY 2006 New 
Technology APCs which were assigned based on the blended methodology 
described above to clinical APC(s) for CY 2007. Following that meeting, 
interested parties provided us with CY 2005 charge and cost information 
from six hospitals that provided MEG services. These external data 
showed wide variation in hospitals' costs and charges for MEG 
procedures, with

[[Page 68027]]

generally higher values for CPT code 95965 and lower values for CPT 
codes 95966 and 95967 but no consistent proportionate relationship 
among those costs and charges. In some cases, the charges and costs for 
CPT codes 95966 and 95967 were quite similar for the two related 
services, one of which describes MEG for a single modality of evoked 
magnetic fields and the other that describes MEG for each additional 
modality of evoked magnetic fields. The individual hospital cost and 
charge data for specific services demonstrated significant variations 
of up to six fold across the hospitals, with an apparent inverse 
relationship between the numbers of services provided and the costs of 
the procedures. This finding was not unexpected, given the dependence 
of MEG procedures on the use of expensive capital equipment. As we have 
previously stated, our OPPS payment rates generally reflect the costs 
that are associated with providing care to Medicare beneficiaries in 
cost-efficient settings. For emerging technologies, we establish 
payment rates for new services that lack hospital claims data based on 
realistic utilization projections for all such services delivered in 
cost-efficient hospital outpatient settings. In the CY 2007 OPPS 
proposed rule, we indicated that since we now had 4 years of hospital 
claims data for MEG procedures and because MEG was no longer a new 
technology, we did not believe these external data from six hospitals 
that performed MEG services in CY 2005 provided a better estimate of 
the hospital resources used in MEG procedures during the care of 
Medicare beneficiaries than our standard OPPS historical claims 
methodology.
    We agreed with the APC Panel and proposed to accept their 
recommendation to move the MEG CPT codes into clinical APCs for CY 
2007. While the volumes for the MEG procedures are low, almost all 
procedures, including those with very low Medicare volume, are assigned 
to clinical APCs under the OPPS, with their payment rates based on the 
median costs of their assigned APCs. Therefore, we proposed to assign 
CPT code 95965 to new clinical APC 0038 (Spontaneous MEG), with a 
proposed median cost of $3,166.30, and to assign both CPT codes 95966 
and 95967 to APC 0209 (Level II MEG, Extended EEG Studies, and Sleep 
Studies), with a proposed median cost of $709.36. We believed that the 
assignment of CPT codes 95966 and 95967 to APC 0209 was appropriate 
because MEG studies were similar to EEGs and sleep studies in measuring 
activity of the brain over a significant time period, and our hospital 
claims data showed that their hospital resources were also relatively 
comparable. MEG procedures and their CY 2007 proposed APC assignments 
were displayed in Table 9 published in the CY 2007 OPPS proposed rule 
(71 FR 49556), which has been reproduced in Table 9 of this final rule 
with comment period and updated to include the final status indicators, 
APC assignments, and APC median costs for CY 2007.
    Comment: Most of the commenters agreed with the APC assignments for 
both CPT codes 95965 and 95967 but requested that CMS reconsider the 
APC assignment for CPT code 95966. The commenters supported the 
establishment of a separate APC for CPT code 95965 and its proposed 
payment rate. They also agreed that CPT code 95967 is an add-on code 
that is always used in conjunction with CPT codes 95965 or 95966 and is 
less costly to perform. They generally agreed with the proposed APC 
assignment and payment rate for CPT code 95967, despite the very low 
volume of OPPS claims for the procedure. The commenters disagreed with 
the proposed APC and payment rate for CPT code 95966. They indicated 
that MEG is a highly specialized service performed in a limited number 
of hospitals in the U.S. Because the service is not commonly performed, 
the commenters acknowledged that Medicare beneficiaries represent only 
a small number of patients who receive MEG services because epilepsy 
surgery is rarely performed on elderly patients, which further explains 
the very low volume of these services in the Medicare claims data. 
While the commenters agreed with the proposed APC assignments for CPT 
codes 95965 and 95967, they believed that the resources required to 
perform 95966 were significantly higher than the payment rate reflected 
in APC 0209, its proposed assignment for CY 2007. The commenters 
indicated that the costs of MEG services were substantially higher than 
the EEG or sleep study services that are also assigned to APC 0209. As 
such, the commenters believed that CPT code 95966 should be assigned to 
its own APC at a rate equal to 50 percent of the payment rate for CPT 
code 95965, or approximately $1,550. They believed that this payment 
rate was supported by the hospital cost data for the six hospitals 
providing a high volume of MEG services, which were provided to CMS and 
discussed in the CY 2007 OPPS proposed rule.
    Response: We appreciate the commenters' input and suggestions. 
However, given that we have 4 years of hospital claims data for MEG 
procedures and because MEG is no longer a new technology, we believe 
that the proposed APC assignment for CPT code 95966 is appropriate. If 
we were to assign CPT code 95966 to its own clinical APC, the median 
cost of that APC would be the median cost of CPT code 95966 of $709 
from CY 2005 claims data, quite consistent with the median cost of APC 
0209. We do not assign payment rates for clinical APCs based upon 
speculative relationships of the costs of its services to payments for 
other services. Instead, the standard OPPS methodology to develop the 
median cost of a clinical APC upon which a specific procedure's payment 
is based is to establish the APC median from claims data for all of the 
services assigned to the APC. As we have indicated above, while the 
volumes of MEG procedures are low, almost all procedures, including 
those with very low Medicare volume, are assigned to clinical APCs 
under the OPPS, with their payment rates based on the median costs of 
their assigned APCs. Taking into consideration our hospital claims data 
for CPT code 95966 from the last several years, we continue to believe 
that its assignment to APC 0209 is appropriate, and that the service is 
sufficiently similar to other diagnostic procedures also residing in 
the APC. Therefore, for CY 2007, we are assigning CPT code 95965 to APC 
0038, with a final CY 2007 median cost of $3,270, and CPT codes 95966 
and 95967 to APC 0209, with a final CY 2007 median cost of $687.
    Comment: One commenter indicated that the claims data cited in the 
CY 2007 OPPS proposed rule for CPT codes 95965, 95966, and 95967 were 
based both on incomplete and inaccurate claims data. The commenter 
submitted copies of paid Medicare claims from CY 2005 for CPT code 
95965, which included nine claims that reflected 5 months of data, each 
representing total charges greater than the CY 2007 proposed payment 
rate for CPT code 95965. The commenter requested that CMS consider 
these claims in determining the appropriate APC assignments for the MEG 
services.
    Response: We confirmed that the claims data submitted to us are 
accurately reflected in the CY 2005 claims data used for the CY 2007 
OPPS update. Consequently, we believe that our claims data adequately 
reflect the costs associated with providing the MEG service identified 
by CPT code 95965. In determining a hospital's cost for a service, we 
take the individual hospital's departmental CCR and multiply this by 
the total charge on a

[[Page 68028]]

single claim for that service. In the event there is no applicable 
departmental CCR, we use the overall hospital-specific CCR. For this CY 
2007 OPPS update, the average overall hospital CCR is 0.30142. 
Multiplying this average CCR by the typical MEG procedure charge of 
about $10,500 on the claims provided to us yields a cost for CPT code 
95965 of about $3,165, consistent with the final CY 2007 median cost of 
APC 0038 of about $3,270. This median cost provides the basis for 
establishing the procedure's payment rate. Overall, we believe the 
claims provided by the commenter help to validate our final CY 2007 APC 
0038 assignment of CPT code 95965, with its payment rate calculated 
according to our standard OPPS methodology.
    After carefully reviewing the data and considering the public 
comments received, we are finalizing our proposal for APC assignment 
for MEG as shown in Table 9 without modification.

                                                        Table 9.--CY 2007 APC Assignment for MEG
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                           Final CY 2007
    HCPCS code         Short descriptor          CY 2006 SI          CY 2006 APC       CY 2006           CY 2007 SI        Final CY 2007    APC median
                                                                                    payment rate                                APC            cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
95965.............  Meg, spontaneous.....  S.....................            1523       $2,750.00  S....................            0038       $3,270.35
95966.............  Meg, evoked, single..  S.....................            1514        1,250.00  S....................            0209          687.26
95967.............  Meg, evoked, each      S.....................            1510          850.00  S....................            0209          687.26
                     additional.
--------------------------------------------------------------------------------------------------------------------------------------------------------

e. Other Services in New Technology APCs
    Other than the PET, PET/CT, SRS, and MEG new technology services 
discussed in section III.C.2.a. through d. of this preamble, there are 
23 procedures currently assigned to New Technology APCs for CY 2007 for 
which we believed we also had data that were adequate to support their 
assignment to clinical APCs. For CY 2007, we proposed to reassign these 
procedures to clinically appropriate APCs, applying their CY 2005 
claims data to develop their clinical APC median costs upon which 
payments would be based. These procedures and their proposed APC 
assignments were displayed in Table 10 of the CY 2007 OPPS proposed 
rule. This table has been reproduced as Table 10 at the end of this 
section and updated with the final status indicators, APC assignments, 
and median costs.
    We received many comments concerning the proposed reassignment of 
other new technology procedures listed in Table 10 to clinical APCs for 
CY 2007. A summary of the comments and our responses follow:
(1) Breast Brachytherapy (APCs 0029 and 0030)
    For CY 2007, we proposed to reassign CPT code 19296 (Placement of 
radiotherapy afterloading balloon catheter into the breast for 
interstitial radioelement application following partial mastectomy, 
includes imaging guidance; on date separate from partial mastectomy) 
from New Technology APC 1524 (New Technology Level XIV--($3000-$3500)) 
to clinical APC 0030 (Level III Breast Surgery) with a proposed median 
cost of $2,516.94. We also proposed to reassign CPT code 19297 
(Placement of radiotherapy afterloading balloon catheter into the 
breast for interstitial radioelement application following partial 
mastectomy, includes imaging guidance; concurrent with partial 
mastectomy) from New Technology APC 1523 (New Technology Level XXIII--
($2500-$3000)) to clinical APC 0029 (Level II Breast Surgery), with a 
proposed median cost of $1,738.75.
    Comment: Numerous commenters requested that CMS maintain CPT code 
19296 and CPT code 19297 in New Technology APCs 1524 and 1523, 
respectively, for another year so that more claims data could be 
collected for both services. They were concerned about the proposed 
significant payment decreases for CPT codes 19296 and 19297 that ranged 
from -23 percent to -37 percent. The commenters also indicated that the 
number of hospital outpatient claims for both codes were low and thus 
inadequate to support their assignment to appropriate clinical APCs. 
The commenters indicated that in developing the proposed rule, CPT code 
19296 had a total of 491 single claims for CY 2005, and only 36 single 
claims were available for CPT code 19297. One commenter was surprised 
that CMS would consider moving CPT code 19297 to a clinical APC with 
only 36 single claims, while CPT code 19298 (Place breast rad tube/
caths), with 49 single claims for CY 2005, would continue to be 
assigned to New Technology APC 1524.
    The commenters generally urged CMS to reevaluate the proposed 
clinical APCs for these procedures, and, if necessary, place them in 
more appropriate APCs that accurately reflected the costs and clinical 
characteristics of these services. Many commenters requested that CMS 
either continue to assign CPT codes 19296 and 19297 to their current CY 
2006 New Technology APCs for CY 2007, or place them in APC 0648, 
retitled ``Level IV Breast Surgery,'' which had a proposed median cost 
of $3,012.92 and a CY 2006 title of ``Breast Reconstruction with 
Prosthesis.'' As to our proposed CY 2007 APC assignments, for these 
codes, the commenters indicated that the other procedures in APCs 0030 
and 0029 did not use high cost devices, and the median costs of the 
various procedures assigned to these APCs violated the 2 times rule 
when the device-dependent median costs of CPT codes 19296 and 19297 
were considered. The commenters further added that the procedures 
within these APCs were not clinically homogeneous and recommended that 
we reassign CPT codes 19296 and 19297 to APC 0648 (Breast 
Reconstruction with Prosthesis), which contained procedures that were 
more similar to the brachytherapy catheter insertion procedures in 
terms of their clinical characteristics and use of costly devices.
    Response: As we have stated previously, we retain services within 
New Technology APC groups until we gather sufficient claims data to 
enable us to assign the services to clinically appropriate APCs. This 
policy allows us to move services from New Technology APCs in less than 
2 years if sufficient data are available. It also permits us to retain 
services in New Technology APCs for more than 3 years if sufficient 
data upon which to base a decision for reassignment have not been 
collected. In the case of CPT codes 19296 and 19297, the predecessor 
codes for these services were created in April 2004. CPT code 19296 was 
previously described by HCPCS code C9715 (Placement of balloon catheter 
into the breast for interstitial radiation therapy following a partial 
mastectomy; delayed), and CPT code 19297 was described by HCPCS code 
C9714 (Placement of balloon catheter into the breast for interstitial

[[Page 68029]]

radiation therapy following a partial mastectomy; concurrent/
immediate). Both predecessor codes were assigned to New Technology APCs 
when the codes were announced in the April update of the CY 2004 OPPS 
(Transmittal 132, dated March 30, 2004). Specifically, HCPCS code C9715 
was assigned to New Technology APC 1524 and HCPCS code C9714 was 
assigned to New Technology APC 1523. Consequently, we believe we have 
sufficient data from almost 3 years of hospital claims to assign both 
CPT codes 19296 and 19297 to clinically appropriate APCs. We recognize 
that, in the case of CPT code 19297 which is an add-on code to a 
partial mastectomy service, single bills would likely always be 
miscoded and available in only small numbers, because the correctly 
coded claims would be multiple procedure claims that we could not use 
for ratesetting.
    However, in light of the comments received and our review of all 
the information provided by the commenters, we reconsidered the 
proposed APC assignments for CPT codes 19296 and 19297. We agree with 
the commenters that the clinical APC assignments for CPT codes 19296 
and 19297 should accurately reflect the costs of the procedures, as 
well as their clinical features. We note that the final CY 2005 median 
cost for CPT code 19296 is $3,041.58 based on 537 (of 860 total) single 
claims, and the final CY 2005 median cost for CPT code 19297 is 
$1,322.03 based on 36 single claims (of 443 total claims). As noted 
previously, we do not believe the median cost of CPT code 19297 is 
calculated based upon correctly coded claims. Therefore, after full 
consideration of the public comments received, we believe it is 
appropriate for CY 2007 to assign both services to clinical APC 0648 
with an APC title of ``Level IV Breast Surgery'' and a final median 
cost of $3,130.45. We believe this is the most appropriate assignment 
for both procedures, when we consider their clinical and resource 
characteristics in the context of other procedures also assigned to APC 
0648.
    APC 0648 is assigned status indicator ``T,'' which means that when 
a service assigned to it is reported with a lower priced service (for 
example, a mastectomy procedure) that is also assigned status indicator 
``T,'' payment for the lower priced service would be reduced by 50 
percent. This reduction in payment reflects the efficiencies that occur 
when a lower paid service is performed during the same operative 
session as a higher paid surgical procedure. We believe this reduction 
is appropriate due to efficiencies that may be gained when both 
services are performed in a single session. As for CPT code 19298, 
because there was no predecessor code to describe this procedure, which 
was new in CY 2005, we only have 1 year of claims data. Therefore, we 
are continuing to assign this code to New Technology APC 1524 for CY 
2007 to enable us to collect additional data for appropriate 
ratesetting in the future.
    Comment: Several commenters indicated that the procedure associated 
with CPT codes 19296 and 19297 requires the use of a specialized 
catheter that has a list price of $2,750, which is more costly than the 
proposed payment rate for APC 0030 or APC 0029. One commenter added 
that hospitals do not receive discounts or rebates on the unique 
catheters, and that regardless of whether the procedure is performed at 
the time of lumpectomy or during future surgery, the cost of the 
catheter is still the same in both cases.
    Response: As noted above, after carefully considering all the 
public comments received, we have reassigned CPT codes 19296 and 19297 
to APC 0648, a device-dependent APC, for CY 2007. The final median cost 
for this device-dependent APC was calculated using only claims that 
contained appropriate device HCPCS codes for all the procedures 
assigned to it with nontoken charges for the devices as discussed in 
section IV.A.2 of this preamble. The median cost from the subset of 
claims reporting a device HCPCS code for the brachytherapy catheter was 
$3,469.85 for CPT code 19296 and $3,379.97 for CPT code 19297. We 
believe that payment for APC 0648 accurately reflects the resources and 
costs associated with performing these device-dependent brachytherapy 
catheter insertion procedures. To ensure that their future claims 
include charges for the necessary devices to assist in ratesetting, we 
will implement procedure-to-device edits for both of these services in 
CY 2007. In order to receive payment for the two procedures to insert 
brachytherapy balloon catheters, hospitals will be required to report 
the appropriate device HCPCS code or their claims will be returned to 
them for correction.
    Comment: Several commenters were concerned about the proposed 
assignment of status indicator ``T'' to both CPT codes 19296 and 19297. 
They observed that the indicator would always reduce the payment for 
CPT code 19297 by 50 percent.
    Response: Based on the final CY 2007 assignment of CPT code 19297 
to APC 0648, we believe this reduction is appropriate due to 
efficiencies that may be gained when both the partial mastectomy and 
placement of brachytherapy catheter procedures are performed in a 
single operative session. According to the CPT manual, CPT code 19297 
would be reported with CPT code 19160 (Mastectomy, partial (e.g., 
lumpectomy, tylectomy, quadrantectomy, segmentectomy)) or 19162 
(Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, 
segmentectomy); with axillary lymphadenectomy). These codes are 
assigned to APCs 0028 (Level I Breast Surgery), with a final CY 2007 
median cost of $1,178.12, and 0693 (Breast Reconstruction), with a 
final CY 2007 median cost of $2,260.98, respectively. In cases where 
the partial mastectomy is performed with concurrent placement of a 
brachytherapy balloon catheter into the breast, payment for the 
nondevice-dependent partial mastectomy procedure would be appropriately 
reduced by 50 percent, while full payment would be provided for the 
device-dependent procedure described by CPT code 19297, consistent with 
the expected resource efficiencies when these procedures are performed 
in a single session.
    After carefully considering all public comments received, we are 
finalizing our CY 2007 proposal with modification to reassign CPT codes 
19296 and 19297 from New Technology APCs to clinical APC 0648, retitled 
``Level IV Breast Procedures,'' with a final CY 2007 median cost of 
$3,130.45. We also are implementing appropriate procedure-to-device 
edits for both of these procedures.
(2) Radiofrequency Ablation (APCs 0050 and 0423)
    For CY 2007, we proposed to reassign CPT code 20982 (Ablation, bone 
tumor(s) (e.g., osteoid osteoma, metastasis), radiofrequency, 
percutaneous, included computed tomographic guidance) from New 
Technology APC 1557 (New Technology--Level XX ($1800-$1900)) to APC 
0050 (Level II Musculoskeletal Procedures Except Hand and Foot), with a 
proposed median cost of $1,535.66.
    We also proposed that CPT code 50592 (Ablation, one or more renal 
tumor(s), percutaneous, unilateral radiofrequency), which was a new CPT 
code for CY 2006, and CPT code 47382 (Ablation, one or more liver 
tumor(s), percutaneous, radiofrequency) continue to be assigned to APC 
0423 (Level II Percutaneous Abdominal and Biliary Procedures), with a 
proposed median cost of $2,410.33.
    Comment: One commenter objected to the proposed payment for APC 
0423 and

[[Page 68030]]

the placement of CPT codes 47382 and 50592 in APC 0423 because the 
commenter believed that the proposed payment was too low to adequately 
compensate hospitals for the required radiofrequency electrode and the 
necessary services. One commenter also asked that CPT code 20982 be 
reassigned to APC 0051 (Level III Musculoskeletal Procedures Except 
Hand and Foot) to pay a more appropriate amount. The commenter provided 
a comparison to the MPFS practice expense inputs that showed that the 
supply, clinical time, and capital expense for performing CPT code 
20982 was about $2,100. Moreover, the commenter asked that CMS ensure 
that a forthcoming CPT code for ablation of a lung tumor be assigned to 
an APC that would make appropriate payment for both the electrode and 
the services. The commenter stated that the electrodes used in these 
services typically cost from $900 to $2,500, with an approximate 
average of $1,500. The commenter asked that CMS grant its pass-through 
device category application, establish a new device category code for 
radiofrequency electrodes for pass-through payment, and designate APCs 
0423, 0132 (Level III Laparoscopy), and 0050 as device-dependent APCs 
and implement appropriate procedure-to-device edits.
    Response: The MPFS is a different payment system that establishes 
payment rates based on a methodology that is wholly unrelated to the 
OPPS setting of relative weights, so its practice expense costs are not 
applicable to the OPPS. However, in this final rule with comment 
period, we are reassigning CPT code 20982 to APC 0051 for CY 2007 
because we agree, based on review of our historical claims data and 
final CY 2005 claims, that CPT code 20982 is more appropriately 
assigned to APC 0051 than to APC 0050 from hospital resource and 
clinical perspectives. However, we are retaining CPT codes 47382 and 
50592 in APC 0423, with a median cost established based upon our 
standard OPPS methodology, because we believe that we have sufficient 
claims data for CPT code 47382, which was created in CY 2002. We have 4 
years of claims data for this procedure, with hundreds of single claims 
from CY 2005 that reflect a stable code-specific median cost in 
comparison with CY 2004 claims. For CY 2007, CPT code 47382 is the only 
code assigned to APC 0423 that contributes claims data to the median 
cost calculation for the APC. We also believe that CPT code 50592, 
which has no CY 2005 claims data because it was new for CY 2006, is 
similar to CPT code 47382 based on clinical and resource 
considerations. Therefore, it is most appropriately assigned to the 
same clinical APC. Moreover, because CPT code 47382 uses devices that 
never had pass-through status, we have not placed any of the CPT codes 
for radiofrequency ablation procedures in specialized APCs, nor do we 
consider their APCs to be device-dependent. Because the device is well-
established in its use for radiofrequency ablation of liver tumors, we 
believe that hospital charges for the procedure contain the charges the 
hospital considers are appropriate for the electrode and other required 
supplies. This is similar to our treatment of CPT code 66984 
(Extracapsular cataract removal with insertion of intraocular lens 
prosthesis (one stage procedure), manual or mechanical technique (e.g., 
irrigation and aspiration or phacoemulsification)). This is a well-
established service that predates the OPPS and that uses a device that 
was never a pass-through device. We also do not consider its APC to be 
device-dependent.
    We also are assigning new CPT code 32998 (Ablation therapy for 
reduction or eradication of one or more pulmonary tumor(s) including 
pleura or chest wall when involved by tumor extension, percutaneous, 
radiofrequency, unilateral) to APC 0423 because we have no reason to 
believe that the resources required for the newly coded service differ 
in any substantive way from the resources required for longstanding CPT 
code 49382. This new CPT code's assignment is open to comment in this 
final rule with comment period. We do not make pass-through device 
category determinations through rulemaking, nor do we create new device 
category codes outside of the pass-through process. Because there is no 
specific device code to describe the radiofrequency ablation electrode, 
we are unable to implement procedure-to-device edits for any of these 
procedures.
    After carefully considering the public comments received, we are 
finalizing our proposal with modification. CPT code 20982 is reassigned 
to APC 0051 for CY 2007, with a median cost of $2,510.95. CPT codes 
47382 and 50592 continue to be assigned to APC 0423 for CY 2007, with a 
median cost of $2,283.08. New CPT code 32998 is also assigned to APC 
0423 for CY 2007, and this assignment is open to comment in this final 
rule with comment period.
(3) Extracorporeal Shock Wave Treatment (APC 0050)
    For CY 2007, we proposed to reassign CPT code 28890 (Extracorporeal 
shock wave, high energy, performed by a physician, requiring anesthesia 
other than local, including ultrasound guidance, involving the plantar 
fascia) and CPT code 0102T (Extracorporeal shock wave, high energy, 
performed by a physician, requiring anesthesia other than local, 
involving lateral humeral epicondyle) from New Technology APC 1547 (New 
Technology--Level X ($800-$900)) to clinical APC 0050 (Level II 
Musculoskeletal Procedures Except Hand and Foot), which had a proposed 
payment rate of $1,542.47.
    Comment: One commenter on our CY 2006 final rule with comment 
period was concerned that our assignment of new CPT code 28890 to APC 
1547 may be insufficient to appropriately pay for the costs associated 
with its performance and facility costs in the outpatient setting. The 
commenter admitted that it did not have actual cost data for supplies 
and equipment used in the hospital outpatient setting. Nevertheless the 
commenter was concerned that the $850 payment rate for services 
assigned to APC 1547 may be insufficient for this service the OPD. The 
commenters on our CY 2007 OPPS proposed rule believed that our proposed 
reassignment of CPT codes 28890 and 0102T to APC 0050 was appropriate 
for CY 2007 until the Medicare hospital claims data become more robust. 
Several commenters supported our proposal to reassign CPT code 28890 
and CPT code 0102T from New Technology APC 1547 to clinical APC 0050. 
The commenters believed that APC 0050 appropriately reflects the true 
costs and clinical resources associated with CPT code 0102T. One 
commenter indicated that the costs of the procedures currently 
classified under clinical APC 0050 are not dissimilar to the median 
cost of its predecessor code, specifically, HCPCS code C9720 (High-
energy (greater than 0.22mj/mm2) extracorporeal shock wave (ESW) 
treatment for chronic lateral epicondylitis (tennis elbow)), and 
therefore, agreed with our proposed assignment. However, one commenter 
believed that the true resource costs of CPT codes 28890 and 0102T are 
not fully reflected in the CY 2005 claims data upon which CY 2007 
payment rates are based. Therefore, the commenter recommended that CMS 
adopt the proposed assignments of these CPT codes to APC 0050, but that 
CMS continue to track and evaluate its claims data as additional claims 
data become available.
    However, the commenter questioned our assignment of CPT code 0101T 
(Extracorporeal shock wave involving musculoskeletal system, not 
otherwise

[[Page 68031]]

specified, high energy) to APC 0050, stating that this code describes a 
variety of unspecified procedures for which we have no CY 2005 claims 
data. The commenter recommended that we not assign CPT code 0101T to 
APC 0050 or to any inappropriately low-priced New Technology APC.
    Response: Concerning the comment to our CY 2006 assignment of CPT 
code 28890, we note that the OPPS payment is for the technical or 
facility portion of the payment only. The physician performing the 
procedure would also bill CMS for the professional services in 
providing the procedure. Therefore, the CY 2006 OPPS payment for APC 
1547 was not for both the performance and facility fee as suggested by 
the commenter. Nevertheless, in our proposed rule for CY 2007, we 
proposed reassigning CPT code 28890 to APC 0050, Level II 
Musculoskeletal Procedures Except Hand and Foot, with a proposed 
payment rate of $1,542.47. Prior to the introduction of this CPT code 
in CY 2006, hospitals reported HPCPS code C9721 (High-energy (greater 
than 0.22mj/mm2) extracorporeal shock wave (ESW) treatment 
for chronic plantar fasciitis), to describe the service. This C-code 
had a median cost of about $1,794 based on CY 2005 claims, consistent 
with the proposed payment rate for APC 0050.
    We appreciate the support for our proposed reassignment of ESWT CPT 
codes 28890 and 0102T to APC 0050 for CY 2007. Concerning the objection 
to assigning CPT code 0101T to APC 0050 due to the lack of claims data, 
we believe that the clinical characteristics and expected resource use 
for CPT code 0101T will be similar to other ESWT treatments such as 
those described by CPT codes 28890 and CPT 0102T. As indicated in our 
CY 2007 OPPS proposed rule (71 FR 49549), some of the new Category III 
CPT codes describe services that we have determined to be similar in 
clinical characteristics and resource use to HCPCS codes in an existing 
APC. In these instances, we may assign the Category III CPT code to the 
appropriate clinical APC. In the case of CPT code 0101T, we believe 
this procedure is similar in clinical characteristics and resource use 
to CPT code 28890 and CPT code 0102T.
    After carefully considering the public comments received, we are 
finalizing our proposal without modification to assign CPT codes 28890, 
0102T, and 0101T to APC 0050 for CY 2007.
(4) Insertion of Venous Access Device With Two Ports (APC 0623)
    For CY 2007, we proposed to reassign CPT code 36566 (Insertion of 
tunneled centrally inserted central venous access device, requiring two 
catheters via two separately venous access sites: with subcutaneous 
port(s)) from New Technology APC 1564 (New Technology--Level XXVII 
($4500-$5000)), to APC 0623 (Level III Vascular Access Procedures), 
with a proposed median cost of $1,703.94. At its August 2006 meeting, 
the APC Panel recommended that this procedure be moved to an APC with a 
payment rate no less than that of New Technology APC 1524 (New 
Technology--Level XXIV ($3000-$3500)) and more than that of New 
Technology APC 1564 (New Technology--Level XXVII ($4500-$5000)). The 
APC Panel also recommended that CMS establish a procedure-to-device 
edit for the service.
    Comment: Some commenters objected to the proposed payment rate for 
CPT code 36566. The commenters asked that CMS establish the median cost 
for this code based only on claims that contain HCPCS code C1881 
(Dialysis access system, implantable) and that we add a device edit 
that requires that hospitals must bill for HCPCS code C1881 as a 
condition of being paid for CPT code 36566. They indicated that two 
devices, totaling $3,500, are required for the procedures.
    Response: We agree that CPT code 36566, created in CY 2004, should 
be assigned to a device-dependent APC, and we calculated median costs 
for device-dependent APCs in CY 2007 based upon claims that passed the 
device edits and contained nontoken device charges as described in 
section IV.A.2 of this preamble. When we calculated the median cost of 
CPT 36566 based only on that subset of claims with HCPCS code C1881, 
its median cost was $5,100.26. We are generally accepting the APC 
Panel's recommendation to assign CPT code 36566 to an APC with an 
appropriate payment rate and to establish a procedure-to-device edit 
for CY 2007. For CY 2007, we have placed CPT code 36566 in new APC 0625 
(Level IV Vascular Access Procedures) because there is no currently 
existing clinical APC where CPT code 36566 could appropriately be 
reassigned based on clinical and resource considerations. We have 
established APC 0625 as a device-dependent APC because the APCs for the 
vascular access device services that require devices of significant 
cost generally have been considered device-dependent since the 
inception of the OPPS. We have established a device edit, effective for 
services on or after January 1, 2007, that will not provide payment for 
CPT code 36566 unless an appropriate device HCPCS code is also reported 
on the claim. We have calculated the median cost of APC 0625 for CY 
2007 using only claims that contain nontoken charges for HCPCS code 
C1881.
    After carefully considering the public comments received, we are 
finalizing our CY 2007 proposal with modification. We are assigning CPT 
code 36566 to APC 0625, with a median cost of $5,100.26, and 
establishing an appropriate procedure-to-device edit for CY 2007.
(5) Stereotactic X-ray Guidance (APC 0257)
    For CY 2007, we proposed to reassign CPT code 77421 (Stereoscopic 
x-ray guidance) from New Technology APC 1502 (New Technology--Level II 
($50-$100)) to clinical APC 0257 (Level I Therapeutic Radiologic 
Procedures), with a proposed median cost of $60.
    Comment: Some commenters expressed concern about our proposal to 
reassign CPT code 77421 from New Technology APC 1502 to clinical APC 
0257. The commenters indicated that the proposed payment rate of $60.14 
for APC 0257 was insufficient and did not adequately cover the actual 
costs associated with providing the guidance service described by CPT 
code 77421. In addition, the commenters believed that the other 
services currently assigned to APC 0257 were significantly different 
from CPT code 77421. The commenters stated that the stereotactic x-ray 
guidance procedure is considerately more sophisticated and 
technologically more complex, and thus, more resource intensive, than 
the procedures in APC 0257. Furthermore, the commenters cited the 
global payment rate of $151.59 for CPT code 77421 under the MPFS, and 
requested that we take into consideration the MPFS practice expense 
information for ratesetting rather than relying on very limited 
hospital claims data. Some commenters requested that CMS reassign CPT 
code 77421 to APC 0296 (Level II Therapeutic Radiologic Procedures), 
which had a proposed median cost of $167, to more accurately reflect 
the true costs associated with providing this service. The commenters 
further indicated that the other services assigned to APC 0296 were 
similar clinically and resource-wise to the stereotactic x-ray guidance 
procedure. Other commenters requested that CMS maintain CPT code 77421 
in New Technology APC 1502 with a payment rate of $75 for CY 2007, 
until CMS has more experience with the CPT code. Some commenters noted 
that CMS may have mistakenly cross-walked CY 2005 claims data for C9722 
(Stereoscopic kilovolt x-ray imaging

[[Page 68032]]

with infrared tracking for localization of target volume) to CPT code 
77421, based on the belief that both codes described the same services.
    Response: While CPT code 77421 was made effective on January 1, 
2006, under the OPPS stereoscopic kV x-ray guidance was previously 
reported with HCPCS code C9722, which was made effective January 1, 
2005, and deleted on December 31, 2005, according to our usual practice 
when services previously described by a C-code can be reported with a 
CPT code. Based on our claims data, we found 14,794 single claims (out 
of 15,367 total claims) for HCPCS code C9722 in the CY 2005 data upon 
which we are basing the CY 2007 relative weights. We believe that 
services previously reported with HCPCS code C9722 may now be reported 
with CPT code 77421, although CPT code 77421 may allow reporting of a 
broader set of technologies. We also believe this CY 2005 volume of 
services is sufficient to justify setting a relative weight based on 
claims-based cost information rather than keeping the service in a New 
Technology APC for another year. In addition, our claims information is 
not consistent with a payment for the service through clinical APC 
0296, which has a final median cost of about $164. We note that, of the 
claims available for ratesetting for APC 0257, almost 90 percent of 
them were for HCPCS code C9722; therefore, we are confident that the 
median cost of APC 0257 appropriately reflects the costs of 
stereoscopic x-ray imaging. We also believe the other imaging services 
assigned to APC 0257 share sufficient clinical and resource similarity 
with CPT code 77421 to support their assignment to the same clinical 
APC. Moreover, we again note that the MPFS practice expense information 
for this service is not relevant to the setting of relative weights 
under OPPS.
    After considering all the public comments received, for CY 2007, we 
are adopting as final without modification our proposal to reassign CPT 
code 77421 from New Technology APC 1502 to clinical APC 0257, which has 
a final CY 2007 median cost of $67.06.
(6) Whole Body Tumor Imaging (APC 0408)
    For CY 2007, we proposed to reassign CPT code 78804 
(Radiopharmaceutical localization of tumor or distribution of 
radiopharmaceutical agent(s); whole body, requiring two or more days 
imaging) from New Technology APC 1508 (New Technology--Level VIII 
($600-$700)) to clinical APC 0408 (Level II Tumor/Infection Imaging) 
with a proposed median cost of $309.
    Comment: Several commenters disagreed with the proposed 
reassignment of CPT code 78804, which describes a whole body study that 
requires multiple days of imaging, from New Technology APC 1508 to the 
same new clinical APC 0408 as the assignment of CPT code 78806 
(Radiopharmaceutical localization of inflammatory process; whole body), 
which describes a single day whole body imaging study. While the 
commenters acknowledged that the two procedures use similar resources 
for a day of imaging, they stated that the clinical time and work 
involved in performing a multiple day imaging study is significantly 
more intensive than a single day study; therefore, hospitals incur 
additional costs. As such, the commenters disagreed with our proposal 
to assign the single and multiple day study CPT codes to the same 
clinical APC because the hospital resources are not homogeneous for 
these clinically similar studies. The commenters urged CMS to maintain 
the single day study as described by CPT code 78806 in its current APC 
assignment, specifically APC 0406 (Level I Tumor/Infection Imaging), 
and to create a new APC for CPT code 78804 for assignment of the 
multiple day study. Furthermore, the commenters recommended that the 
payment rate for CPT code 78804 be based on the current claims data for 
the procedure.
    Response: After further review of our CY 2005 claims data and 
consideration of the clinical characteristics of CPT code 78804, we 
agree with the commenters' recommendation to maintain the single day 
study, which is described by CPT code 78806, in its current CY 2006 APC 
0406. We further agree with the commenters' assignment of CPT code 
78804 to a separate APC established as Level II Tumor/Infection 
Imaging, and therefore, have decided to keep this code as the only code 
assigned to APC 0408 for CY 2007. Based on our final revised policy, 
the CY 2007 median cost of APC 0408 is $362.05. The separate APC 
assignments for the single and multiple day tumor/infection imaging 
studies adequately achieve both clinical and resource coherence for the 
services in both APCs. Therefore, we are finalizing our proposed CY 
2007 APC assignment of CPT code 78804 to new clinical APC 0408 for CY 
2007, with modification to the proposal through reconfiguration of APC 
0408 as described above.
(7) Gastroesophageal Reflux Test With pH Electrode (APC 0361)
    For CY 2007, we proposed to reassign CPT code 91035 (Esophagus, 
gastroesophageal reflux test; with mucosal attached telemetry ph 
electrode placement, recording, analysis and interpretation) from New 
Technology APC 1506 (New Technology--Level VI ($400-$500)) to clinical 
APC 0361 (Level II Alimentary Tests) with a proposed payment of $242.
    Comment: One commenter disagreed with our proposal to reassign CPT 
code 91035 from New Technology APC 1506 to clinical APC 0361. The 
commenter believed that the proposed payment level of $242 for APC 0361 
did not adequately reflect the cost of providing the service and that 
it did not appropriately differentiate between the two types of pH 
monitoring for detection of gastroesophageal reflux disease (GERD): 
capsule-based and catheter-based. (CPT code 91035 describes the 
capsule-based pH monitoring service while CPT code 91034 describes the 
catheter-based pH monitoring procedure.) The commenter believed that 
the resource costs for the two procedures are significantly different, 
and as such, each procedure should be placed in a separate APC to 
accurately reflect the costs of providing the services. The commenter 
indicated that the average cost of the capsule is about $184, which is 
significantly higher than the cost of the catheter used for pH 
monitoring that is priced at about $45. In addition, the commenter 
requested that CPT code 91035 be designated as a device-dependent 
procedure, and also requested that CMS establish a C-code for the 
capsule to appropriately track its cost. The commenter also requested 
that CMS compare the costs of single claims with claims that include an 
endoscopy procedure, with which the pH capsule procedure is very 
commonly performed, to ensure that all costs were captured and based on 
the most likely clinical scenario when determining the appropriate 
payment rate for CPT code 91035.
    Response: Since April 2004, the procedure described by CPT code 
91035 has been designated as a new technology service under the OPPS. 
While CPT code 91035 was not effective for reporting until January 1, 
2005, its predecessor code, specifically HCPCS code C9712 (Insertion of 
a pH capsule for measurement and monitoring of gastroesophageal reflux 
disease, includes data collection and interpretation) was designated as 
a new technology service and assigned to New Technology APC 1506 from 
April 2004 until December 31, 2004, when the code was deleted and 
replaced with CPT code 91035. CPT code 91035 was then assigned to the 
same New Technology

[[Page 68033]]

APC for CY 2005, with a payment rate of $450. As usual, in determining 
the initial payment level for this service, we took into consideration 
the costs associated with the procedure, including the necessary 
capsule device.
    We do not believe that our claims data from CYs 2004 and 2005 
demonstrate that the resources associated with a capsule-based pH 
monitoring procedure are significantly greater than those required for 
a catheter-based pH monitoring procedure, leading to their 
inappropriate assignments to the same clinical APC. Based on our CY 
2005 claims data, the median costs for each procedure are relatively 
comparable: $260 for CPT code 91034 (based on 2,982 single claims) and 
$300 for CPT code 91035 (based on 1,160 single claims). We believe that 
both procedures are fairly similar in terms of device cost, clinical 
staff time, and other facility resources required for performing the 
procedures. We note that the median cost for CPT code 91035 was based 
upon 1,160 single claims out of 4,777 total claims for the procedure. 
While we understand that capsule-based pH monitoring is often initiated 
in association with an endoscopy procedure, we have no reason to 
believe that our median cost from single claims calculated according to 
our standard OPPS methodology understates the cost of the procedure. 
Indeed, we would expect that the resources could be less if the service 
were performed in association with another surgical procedure because 
of efficiencies, although there would be no payment reduction because 
APC 0361 has a status indicator of ``X.''
    With respect to designation of the procedure as device-dependent, 
we typically have only designated APCs as device-dependent in the 
context of historical payment adjustments provided for these APCs. Many 
device-intensive procedures appropriately reside in clinical APCs along 
with procedures that do not require expensive devices. Currently device 
HCPCS codes are only established when new pass-through device 
categories are approved. Therefore, we will not create a new device 
code to track charges for this particular device that has not had pass-
through status. We expect that hospitals will include their charges for 
the cost of the capsule either in the line-item charge for the pH 
monitoring procedure or under a separate revenue code line on their 
claims.
    Because we believe that the median cost of APC 0361 appropriately 
represents the costs and resources involved in performing both capsule-
based and catheter-based pH monitoring procedures, and these services 
are clinically similar, we are finalizing our assignment of CPT code 
91035 to APC 0361 for CY 2007 without modification.
(8) Home International Normalized Ratio (INR) Monitoring (APC 0604)
    Since CY 2002, home INR monitoring services have been described by 
two G-codes, specifically G0248 and G0249, and have been assigned to 
New Technology APCs. These codes were created effective July 2002 in 
the context of a National Coverage Determination (NCD) that covers home 
INR monitoring for patients with mechanical heart valves on warfarin 
that have been anticoagulated for at least 3 months, who undergo an 
educational program on anticoagulation management and use of the device 
prior to its use in the home, and who perform self-testing no more than 
once a week. The G-codes have been assigned to New Technology APCs for 
5 years. Generally, codes remain in New Technology APCs until we can 
determine an appropriate clinical APC, based on the median cost and 
clinical characteristics of the services described by the code. This 
usually ranges from approximately 2 to 3 years.
    In CY 2002, G0248 and G0249 were assigned to a New Technology APC 
with a payment rate of $75. In CY 2003, these codes were reassigned to 
a New Technology APC with a payment rate of $150, and they have 
remained there since that time.
    Our analysis of hospital data for Medicare single and multiple 
claims submitted from CY 2002 through CY 2005 indicates that these 
procedures are rarely performed by hospital outpatient facilities. For 
claims submitted from CY 2002 through CY 2005, our single claims data 
show that there were zero claims submitted during CYs 2002, 2003, and 
2004, and in CY 2005, only nine single claims for G0248 and only seven 
for G0249 are available for ratesetting. Looking at total claims, from 
2002 through 2004, we had fewer than 20 claims for each of the specific 
services.
    In addition, the median costs for these codes are $95 for G0248 and 
$128 for G0249 based on CY 2005 claims. Because we received no single 
claims between CY 2002 and CY 2004 for these codes, we have no prior 
median cost data.
    In the CY 2007 OPPS proposed rule (71 FR 49556), we proposed to 
assign both G0248 and G0249 to clinical APC 0604 (Level I Clinic 
Visits), with a proposed median cost of $49.93. We believe these 
assignments were appropriate based on both clinical and resource 
considerations, in the context of other services also proposed for 
assignment to APC 0604.
    During the August 2006 APC Panel meeting, one presenter recommended 
that we either continue to assign G0248 and G0249 to a New Technology 
APC or move them to an appropriate clinical APC consistent with the 
clinical and resource cost characteristics of providing these services. 
This technology is used in monitoring the adequacy of anticoagulation 
in patients taking warfarin to prevent major thromboembolic events. The 
presenter indicated that providers have been slow to adopt the 
technology because they must purchase the monitors and materials. The 
presenter requested that the codes remain in New Technology APCs or be 
reassigned to clinical APCs that appropriately make payments for the 
costs of providing the services, so that use of this technology 
increases and more data can be collected. The Panel agreed that 
providing payment at an appropriate rate would encourage more use of 
home INR monitoring, which would actively engage patients in their own 
care. The Panel recommended that we assign G0248 and G0249 to APC 0421 
(Prolonged Physiologic Monitoring) for CY 2007.
    Comment: One commenter expressed concern regarding our proposal to 
move home INR monitoring from New Technology APC 1503 (New Technology--
Level III ($100-$200)) to clinical APC 0604. The commenter was 
particularly concerned that the proposed clinical APC 0604, which has a 
payment rate of $49.75, would not compensate for the costs incurred in 
delivering this service. While the commenter understood the reason for 
assigning these codes to a clinical APC because these codes have been 
assigned to a New Technology APC since July 2002 (these codes were made 
effective in July 2002 and announced through the OPPS July 2002 update, 
specifically Transmittal A-02-050, dated June 17, 2002), the commenter 
stated that the technology is fairly new with only a small number of 
hospital claims, which could therefore warrant its continued assignment 
to the current New Technology APC 1503. The commenter also indicated 
that the assignments of HCPCS codes G0248 and G0249 to clinical APC 
0604 were neither economically nor clinically coherent because none of 
the other procedures also proposed for assignment to APC 0604 involved 
the furnishing of equipment and supplies to patients for use in their 
homes or involved care extended over a 4-week period. Therefore, the 
commenter urged CMS to maintain home INR monitoring services

[[Page 68034]]

in New Technology APC 1503 with a payment rate of $150 for at least one 
more year. Alternatively, the commenter requested that CMS assign these 
codes to clinical APC 0421, which had a proposed payment rate of 
$101.47, because the reimbursement rate more closely corresponded with 
the costs of providing the services, and also with the clinical 
characteristics of the other procedure already assigned to this same 
APC.
    Response: As we indicated above, the APC Panel also recommended 
that these two HCPS codes be assigned to APC 0421 for CY 2007. We agree 
with both the commenter and the APC Panel's recommendation to assign 
these codes to APC 0421.
    Therefore, we are finalizing our proposed movement of HCPCS codes 
G0248 and G0249 from New Technology APC 1503 to a clinical APC for CY 
2007 with modification. Effective January 1, 2007, HCPCS codes G0248 
and G0249 will be assigned to APC 0421, with a final median cost of 
$99.43.
(9) Tositumomab Administration and Supply (APC 0442)
    For CY 2007, we proposed to assign HCPCS code G3001 (Administration 
and supply of tositumomab, 450 mg) from New Technology APC 1522 (New 
Technology--Level XXII ($2000-$2500)) to clinical APC 0442 (Dosimetric 
Drug Administration), which had a proposed median cost of $1,515.80.
    Comment: Several commenters, including a pharmaceutical company, 
expressed concern with the CMS proposal to assign HCPCS code G3001 from 
New Technology APC 1522 with a payment rate of $2,250 to clinical APC 
0442. The commenters were concerned that the payment rate of $1,510.52 
that was proposed for APC 0442 would not adequately cover both the cost 
of the product and the administration of the product itself since the 
WAC for the tositumomab product was approximately $2,189. They 
requested that CMS maintain the current payment rate for G3001 of 
$2,250 for CY 2007. Furthermore, one commenter recommended that HCPCS 
code G3001, currently applicable to both doses of the non-radioactive 
component of therapy and its administration, be amended to apply only 
to the unlabeled tositumomab product. The commenter urged CMS to assign 
a specific code that describes the unlabeled tositumomab to enable 
appropriate payment for the product. The commenter added that unlabeled 
tositumomab alone is only FDA approved as part of the overall BEXXAR 
therapeutic regimen, and therefore cannot be used other than as part of 
BEXXAR therapy. The commenter also recommended CMS permit hospitals to 
use a CPT code for the 1-hour administration of the nonradioactive 
component of BEXXAR.
    Response: We first established G3001 in CY 2003. As we stated in 
the CY 2004 OPPS final rule with comment period (68 FR 63443), 
unlabeled tositumomab is not approved as either a drug or a 
radiopharmaceutical, but it is a supply that is required as part of the 
BEXXAR treatment regimen. We do not make separate payment for supplies 
used in services provided under the OPPS. Payments for necessary 
supplies are packaged into payments for the separately payable services 
provided by the hospital. Administration of unlabeled tositumomab is a 
complete service that qualifies for separate payment under its own APC. 
This complete service is currently described by HCPCS code G3001. 
Therefore, we do not agree with the commenter's recommendation that we 
assign a separate code to the supply of unlabeled tositumomab, which 
would not then receive separate payment. Rather, we will continue to 
make separate payment for the administration of tositumomab through 
G3001, and payment for the supply of unlabeled tositumomab is packaged 
into the administration payment.
    Based on our CY 2005 claims data that show a final median cost of 
$1,367 for APC 0442, which contains only the service described by 
G3001, we had 148 single claims for the service. The median cost of 
G3001 from CY 2004 claims is $1,210 based on 69 single claims. We 
expect the annual volume of this service to Medicare beneficiaries to 
remain modest. By CY 2007, G3001 service will have been assigned to a 
New Technology APC for 3 years, providing two full years of claims data 
for our analysis. We believe that the final CY 2007 median cost of APC 
0442 accurately reflects the hospital resources required to perform the 
administration and supply of tositumomab service, and that our data are 
sufficient at this point to support movement of G3001 out of a New 
Technology APC and into an appropriate clinical APC for CY 2007. 
Consequently, we are finalizing the proposed CY 2007 reassignment of 
HCPCS code G3001 from New Technology APC 1522 to clinical APC 0442, 
without modification.
(10) Summary of Other New Technology Procedures Assigned to Clinical 
APCs for CY 2007
    After carefully considering all of the public comments received, we 
are adopting our proposal to reassign the new technology procedures to 
clinically appropriate APCs with modification to the final APC 
assignments for CPT codes 19296, 19297, 20982, 36566, and 78804 as 
shown in Table 10 below.
BILLING CODE 4120-01-P

[[Page 68035]]

[GRAPHIC] [TIFF OMITTED] TR24NO06.015

BILLING CODE 4120-01-C

D. APC-Specific Policies

1. Radiology Procedures
a. Radiology Procedures (APCs 0333, 0662, and Other Imaging APCs)
    At its March 2006 meeting, the APC Panel made three recommendations 
regarding radiology services. These included the following:
     Reaffirmed the CY 2005 recommendation that CMS postpone 
implementation of the multiple procedure reduction policy for imaging 
services as included in the CY 2006 OPPS proposed rule for CY 2007, to 
allow CMS to gather more data on the efficiencies associated with 
multiple imaging procedures that may already be reflected in the OPPS 
payment rates for imaging services.
     Recommended that CMS review payment rates for computed 
tomography (CT) and computed tomographic angiography (CTA) procedures 
to ensure that their payment rates are comparatively consistent and 
that they accurately reflect resource use.
     Recommended that CMS invite comments on ways that 
hospitals can uniformly and consistently report charges and costs 
related to radiology services.
    In the CY 2006 OPPS final rule with comment period (70 FR 68707), 
we indicated that, based on the APC Panel's recommendations and public 
comments received, we decided not to finalize our CY 2006 proposal to 
reduce OPPS payments for some second and subsequent diagnostic imaging 
procedures performed in the same session. Our analyses did not disprove 
the commenters' contentions that there are efficiencies already 
reflected in their hospital costs, and, therefore, in their CCRs and 
the median costs for the procedures. As noted in the CY 2007 OPPS 
proposed rule (71 FR 49567), over the past 7 months, we have conducted 
additional studies of our hospital claims data for single and multiple 
diagnostic imaging procedures, and our analyses support continued 
deferral for CY 2007 of implementation of a multiple imaging procedure 
payment reduction policy in the OPPS. Therefore, we accepted the APC 
Panel's recommendation to not adopt such a policy for CY 2007 pending 
the results of further analyses. Depending upon the findings from such 
studies, in a future rulemaking we may propose revisions to the 
structure of our rates to further refine these rates in the context of 
additional study findings.
    We received numerous public comments concerning our proposal. A 
summary of the comments and responses follow:
    Comment: Numerous commenters supported the CMS proposal to defer 
implementing a multiple imaging

[[Page 68036]]

procedure payment reduction policy in the OPPS for CY 2007. A number of 
commenters reiterated that CMS should never implement such a policy in 
the OPPS, based on the inherent characteristics of the standard 
methodology that is used to establish OPPS payment rates that already 
captures the efficiencies of these multiple services in the CCRs used 
to convert charges to costs on hospital claims. They argued that such 
discounting is not needed and unwarranted, because discounting has 
already been considered in setting the APC weights.
    Response: We continue to be concerned about making appropriate 
payments for imaging services in the common circumstances where 
multiple procedures using the same imaging modality are provided in the 
same encounter. We will continue to study our single and multiple 
outpatient hospital claims for diagnostic imaging procedures and 
consider refinements to our payment rates for these services if results 
from the analyses suggest that changes to our payment policies would 
provide more accurate payments for these services.
    After carefully considering the public comments received, we are 
adopting our proposal to defer implementation of a multiple imaging 
procedure payment reduction for CY 2007, without modification.
    As indicated in the CY 2007 OPPS proposed rule (71 FR 49568), we 
also accepted the APC Panel's recommendation to review the CY 2007 
proposed payment rates for CT and CTA procedures to ensure that their 
rates were comparatively consistent and accurately reflective of 
hospitals' resource costs. Presenters at the March 2006 APC Panel 
meeting indicated to the Panel that hospital resources for CTA 
procedures were similar to those for CT procedures that included scans 
without contrast followed by scans with contrast, but additional 
resources were required for the 3-dimensional reconstruction that was 
part of the CTA procedures. As a result of this image postprocessing, 
CTA scans displayed the vasculature in a 3-dimensional format rather 
than in the 2-dimensional cross-sectional images of conventional CT 
scans. As indicated in our CY 2007 proposed rule (71 FR 49568), based 
upon CY 2005 claims data, the CY 2007 proposed median cost for APC 0333 
for CT procedures that included scans without contrast material, 
followed by contrast scans to complete the studies was $309, and the CY 
2007 proposed median cost for APC 0662 for CTA procedures was $304. As 
has been the case for the past several years, the proposed median costs 
associated with these two APCs were virtually identical to one another 
and were also quite consistent with their historical costs from prior 
years of claims data. The CY 2007 proposed median costs for APCs 0333 
and 0662 were based on about 500,000 and 150,000 single claims, 
respectively. The stability of these APC median costs, based on large 
numbers of single claims, was consistent with our belief that the 
median costs of these APCs accurately reflected hospitals' resource 
use. From CY 2004 to CY 2005, the number of CTA procedures performed in 
the outpatient department increased by 50 percent, whereas the number 
of CT procedures that included a scan without contrast followed by a 
scan with contrast to complete each full study increased by only about 
1 percent. The large annual increases in the OPPS frequencies of CTA 
procedures through CY 2005 provided no evidence that Medicare 
beneficiaries were experiencing difficulty accessing these services in 
the hospital outpatient setting. CTA procedures were being more 
commonly performed for various clinical indications, likely resulting 
in more consistent and efficient use of the associated image 
postprocessing technology. Accordingly, it is not surprising that the 
hospital costs of typical CTA procedures in contemporary medical 
practice were very similar to the hospital costs of the more involved 
and resource-intensive complex CT services that, like CTA procedures, 
included scans without contrast material, followed by scans with 
contrast. Thus, we indicated in the CY 2007 proposed rule that we 
believed that our CY 2007 proposed payment rates for CT and CTA 
procedures were generally consistent with one another and accurately 
reflective of hospitals' resource costs.
    We received several comments concerning our proposal. A summary of 
the comments and our responses follows:
    Comment: Several comments on our proposed payment rate of $302.85 
for the CTA procedures placed in APC 0662 (CT Angiography) indicated 
that the CTA procedures were reimbursed at a lower rate than 
conventional CT procedures, although the utilization costs of CTA 
exceeded conventional CT. The commenters urged CMS to set the payment 
for APC 0662 at a rate equal to the sum of APC 0333 (Computerized Axial 
Tomography and Computerized Angiography without Contrast followed by 
Contrast), which had a proposed payment rate of $307.88, and the 
postprocessing APC, specifically, APC 0282 (Miscellaneous Computerized 
Axial Tomography), which had a proposed payment rate of $95.72. 
Alternatively, the commenters suggested that CMS reassign the CTA 
procedures from APC 0662 to an existing APC that more closely reflected 
the resource costs of performing the procedures.
    Response: While we acknowledge the commenters' concerns, we believe 
that our claims data accurately reflect the resource costs associated 
with providing the CTA services. As we stated in the November 15, 2004 
final rule with comment period (69 FR 65722) and further reiterated in 
the November 10, 2005 final rule with comment period (70 FR 68597), 
accurate cost information about the costs of image reconstruction for 
CTA specifically, and for CT alone as utilized with CTA, would be 
required in order to implement one commenter's suggestion that we make 
the payment rate for CTA (APC 0662) equal to the sum of the rates for 
CT alone (APC 0333) plus image reconstruction (APC 0282). However, such 
cost information is still not available.
    We have had several years of robust claims data for CTA procedures, 
whose code descriptors by definition include the required CT scans and 
image postprocessing, and have no reason to doubt these data. Based on 
the full year of CY 2005 data, we note that the median cost of $295.80 
for APC 0333 (CT) is almost equal to the median cost of $296.70 for APC 
0662 (CTA). Moreover, for specific reasons cited in the CY 2006 OPPS 
final rule (70 FR 68599), we are not reassigning the CTA procedures to 
any other clinical APC(s) for CY 2007. We believe that APC 0662 is 
quite homogeneous and see no other clinical APC where these services 
could be appropriately assigned based on clinical and resource 
considerations. We will apply the same standard OPPS ratesetting 
methodology for CY 2007 that we used for CY 2006 in establishing the 
payment rate for CTA procedures residing in APC 0662.
    After carefully considering the public comments received, we are 
finalizing our proposal for payment of APCs 0333 and 0662 based on 
their median costs established according to the standard OPPS 
methodology, without modification.
    With respect to the APC Panel's recommendation regarding the 
reporting of costs and charges for radiology services, as we noted in 
the proposed rule, CMS requires hospitals to report their costs and 
charges through the cost report with sufficient specificity to support 
CMS' use of cost report data for monitoring and payment. Within 
generally accepted principles of cost

[[Page 68037]]

accounting, we allow providers flexibility to accommodate the unique 
attributes of each institution's accounting systems. For example, 
providers must match the generally intended meaning of the line-item 
cost centers, both standard and nonstandard, to the unique 
configuration of department and service categories used by each 
hospital's accounting system. Also, while the cost report provides 
recommended bases of allocation for the general services cost centers, 
a provider is permitted, within specified guidelines, to use an 
alternative basis for a general service cost if it can justify to its 
fiscal intermediary that the alternative is more accurate than the 
recommended basis. This approach creates internal consistency between a 
hospital's accounting system and the cost report, but cannot guarantee 
the precise comparability of costs and charges for individual cost 
centers across institutions.
    However, in the CY 2007 proposed rule, we indicated that we 
believed that achieving greater uniformity by, for example, specifying 
the exact components of individual cost centers, would be very 
burdensome for hospitals and auditors. Hospitals would need to tailor 
their internal accounting systems to reflect a national definition of a 
cost center. It was not clear that the marginal improvement in 
precision created by such a requirement would justify the additional 
administrative burden. We believed that the current hospital practice 
of matching costs to the general intended meaning of a cost center 
ensures that most services in the cost center would be comparable 
across providers, even if the precise composition of a cost center 
among hospitals differed. Further, every hospital provides a different 
mix of services. Even if CMS specified the components of each cost 
center, costs and charges on the cost report would continue to reflect 
each individual hospital's mix of services. At the same time, internal 
consistency is very important to the OPPS. Costs are estimated on 
claims by matching CCRs for a given hospital to their own claims data 
through a cost center-to-revenue code crosswalk. OPPS relative weights 
are based on the median cost for all services in an APC. The components 
resulting in CCRs for a given revenue code would have to be 
dramatically different for the providers contributing the majority of 
claims used to calculate an APC's median cost in order to impact 
relative weights.
    We accepted the APC Panel's recommendation and specifically invited 
comments on ways that hospitals can uniformly and consistently report 
charges and costs related to all cost centers, not just radiology, that 
also acknowledge the ubiquitous tradeoff between greater precision in 
developing CCRs and administrative burden associated with reduced 
flexibility in hospital accounting practices.
    We received a number of public comments concerning this APC Panel 
recommendation. A summary of the comments and our responses follows:
    Comment: Several commenters agreed that any steps taken to ensure 
greater uniformity in the reporting of costs and charges would have to 
carefully balance the additional administrative burden and loss of 
flexibility in hospitals' accounting practices. They noted that the 
difficulty in applying CCRs to arrive at hospital costs is that this 
requires assumptions of consistency in the relationship of HCPCS codes 
and revenue codes to revenue center service categories on the cost 
report. However, the cost report recognizes service categories that 
reflect the general descriptions of a hospital's service categories, 
but services that were at one time performed in a specific department 
of the hospital may now be performed in many departments of hospitals. 
The commenters noted that inconsistencies occur when determining the 
cost of a service if the CCR utilized in the calculation is from a 
different cost report service category than where the service was 
actually performed. The commenters also urged CMS to recognize the 
limitations and inconsistencies in the preparation of hospital cost 
reports, attributable to both hospital and fiscal intermediary 
behavior. They urged CMS to proceed with care in instructing hospitals 
because hospitals need the flexibility to set charges and allocate 
costs in a manner that makes the most sense for the particular hospital 
based on the mix of services it provides. The commenters noted that 
even small changes in practice and procedures require significant 
systems changes, and that CMS should allow time for dissemination of 
any such changes, coupled with significant provider education.
    Response: We appreciate the commenters' observations. We will 
continue to reflect on the delicate balance between greater accuracy in 
developing CCRs to convert charges to costs under the OPPS and the 
needs of hospitals for flexibility in their accounting practices.
    After carefully considering the public comments received, we will 
continue to seek input on this balance as we work on refining the OPPS 
payment system to pay more accurately for outpatient hospital services.
    For CY 2007, we did not propose to make any changes from CY 2006 in 
our proposed APC assignments of CT, magnetic resonance imaging (MRI), 
and magnetic resonance angiography (MRA) services, preserving the 
longstanding APC groupings of these services. In particular, CT 
services were assigned to APCs 0332 (Computed Tomography without 
Contrast), 0283 (Computed Tomography with Contrast Material), and 0333 
(Computed Tomography without contrast followed by Contrast) based upon 
their nature as studies without contrast, with contrast, and without 
contrast followed by contrast, respectively. MRI and MRA procedures 
were assigned to APCs 0336 (Magnetic Resonance Imaging and Magnetic 
Resonance Angiography without Contrast), 0284 (Magnetic Resonance 
Imaging and Magnetic Resonance Angiography with Contrast), and 0337 
(Magnetic Resonance Imaging and Magnetic Resonance Angiography without 
Contrast followed by Contrast) based upon their characteristics as 
studies without contrast, with contrast, and without contrast followed 
by contrast, respectively.
    Comment: One commenter requested that CMS revise the established 
CT, MRI, and MRA APC groupings to create greater internal clinical and 
resource consistency. The commenter believed that diagnostic services 
performed in the same anatomical region have similar resource 
utilization and should, therefore, be assigned to the same APC 
grouping. The commenter recommended that CMS differentiate among these 
services based on two body regions, the core (including the head, neck, 
thorax, spine, chest, abdomen, and pelvis) and the extremities 
(including the orbit/ear/fossa, maxillofacial region, upper extremity, 
and lower extremity). The commenter argued that because the OPPS was 
being used as the benchmark established by the DRA to limit payment for 
imaging services under the MPFS, this refinement would assist in 
ensuring even greater resource similarity of procedures within imaging 
APCs to establish more accurate payment rates under both the OPPS and 
the MPFS.
    Response: We examined the current APC structure for CT, MRI, and 
MRA services and observed that there were no violations of the 2 times 
rule in any of the APCs. The median costs of the services assigned to 
each APC were relatively close, and we did not identify any code-
specific patterns of significantly increased or decreased

[[Page 68038]]

costs based on the specific anatomical region of the body imaged. We 
believe these APCs as currently structured contain services that are 
quite homogeneous with respect to their clinical and resource 
characteristics. The OPPS provides payments for APC groups of closely 
related procedures, and the current imaging groups provide appropriate 
payments for these services in a manner that is consistent with the 
payment policies of the OPPS. Accordingly, we see no reason to further 
distinguish CT, MRI, and MRA procedures into even smaller, more refined 
groupings. We also do not believe it would be appropriate to adjust 
these APC groups in order to affect the payments for CT, MRI, and MRA 
procedures under the MPFS.
    After carefully considering the public comment received, we are 
finalizing our CY 2007 proposal for payment of CT, MRI, and MRA 
procedures, without modification. b. Computerized Reconstruction (APC 
0417)
    We proposed to assign HCPCS code G0288 (Reconstruction, computed 
tomographic angiography of aorta for surgical planning for vascular 
surgery) to APC 0417 (Computerized Reconstruction) for CY 2007, with a 
proposed median cost of $192.34. This was the same APC assignment as CY 
2006, and this service is the only service assigned to the APC.
    Comment: One commenter strongly opposed the proposed payment amount 
for CY 2007 for HCPCS code G0288. The commenter stated that the OPPS 
proposed payment amount was not nearly enough to cover the hospital's 
costs for providing this important service. The commenter believed that 
implementation of the proposed payment would jeopardize the quality of 
the HCPCS code G0288 procedures that are performed, limit beneficiary 
access to the services, and result in postoperative complications due 
to implantation of poorly fitting stents.
    Response: The payment amount proposed for the APC 0417, to which 
HCPCS code G0288 is the only service assigned, is based on the median 
cost from 6,028 single claims for this one service. We are confident 
that these data provide an accurate representation of hospital costs 
for providing the service. We note that despite reductions in payment 
rates over the last several years, the number of total procedures 
billed under the OPPS for HCPCS code G0288 has risen steadily from 
2,065 in CY 2002, to 4,733 in CY 2003, to 8,421 in CY 2004, and most 
recently to 9,395 in CY 2005. We have no evidence that Medicare 
beneficiaries are having trouble accessing this service based on our 
hospital claims information. We believe that it is appropriate for us 
to use our historical hospital cost data as the basis for the CY 2007 
payment amount. Therefore, we are finalizing our CY 2007 payment rate 
for APC 0417 based on a median cost of $197.95.
c. Cardiac Computed Tomography and Computed Tomographic Angiography 
(APCs 0282, 0376, 0377, and 0398)
    In Addendum B of the CY 2007 proposed rule (71 FR 49832), we 
proposed to assign the eight cardiac computed tomography (CCT) and 
computed tomographic angiography (CCTA) Category III CPT codes to the 
APCs as shown in Table 11 below. These services were new for CY 2006, 
and we did not propose any changes to their APC assignments for CY 
2007.

               Table 11.--Proposed CY 2007 APC Assignments for CCT and CCTA Category III CPT Codes
----------------------------------------------------------------------------------------------------------------
                                                                                                    Proposed CY
                                                                                    Proposed CY      2007 APC
                   CPT code                                Descriptor                2007 APC       assignment
                                                                                    assignment     payment rate
----------------------------------------------------------------------------------------------------------------
0144T.........................................  CT heart wo dye; qual calc......            0398         $261.66
0145T.........................................  CT heart w/wo dye funct.........            0376          306.34
0146T.........................................  CCTA w/wo dye...................            0376          306.64
0147T.........................................  CCTA w/wo, quan calcium.........            0376          306.34
0148T.........................................  CCTA w/wo, strxr................            0377          415.12
0149T.........................................  CCTA w/wo, strxr quan calcium...            0377          415.12
0150T.........................................  CCTA w/wo, disease strxr........            0398          261.66
0151T.........................................  CT heart funct add-on...........            0282           95.72
----------------------------------------------------------------------------------------------------------------

    Comment: Several commenters requested that CMS remove the APC 
assignments for the eight CCT and CCTA procedures because these codes 
fall within the Category III CPT code section, and because they are 
carrier-priced and not assigned any relative value units under the 
MPFS. The commenters believed that the Deficit Reduction Act MPFS 
provisions should not apply to these procedures.
    Response: As we stated in a section III.A.2. of this CY 2007 OPPS 
final rule with comment period, we implement Category III codes that 
are released by the AMA in July of a given year for implementation in 
January of the next year by providing them with new interim assignments 
in the OPPS final rule for the next update year. These CCT and CCTA 
codes were released in July 2005 for implementation in January 2006. We 
received no public comments on their interim final APC assignments 
published in Addendum B of the CY 2006 OPPS final rule with comment 
period. As we indicated in our CY 2007 OPPS proposed rule (71 FR 
49549), some Category III CPT codes describe services that we have 
determined to be similar in clinical characteristics and resource use 
to HCPCS codes in an existing APC. In these instances, we may assign 
the Category III CPT code to the appropriate clinical APC. Other 
Category III CPT codes describe services that we have determined are 
not compatible with an existing clinical APC, yet are appropriately 
provided in the hospital outpatient setting. In these cases, we may 
assign the Category III CPT code to what we estimate is an 
appropriately priced New Technology APC. In other cases, we may assign 
a Category III CPT code to one of several nonseparately payable status 
indicators, including ``N,'' ``C,'' ``B,'' or ``E,'' which we believe 
is appropriate for the specific code. We believe that CCT and CCTA 
procedures are appropriate for separate payment under the OPPS should 
local contractors provide coverage for these procedures, and, 
therefore, they warrant status indicator and APC assignments that would 
provide separate payment under the OPPS. MPFS concerns regarding 
payment limitations for these procedures are outside the scope of this 
final rule with comment period.
    Comment: Many commenters expressed their appreciation of our 
recognition of the CPT codes as separately payable services under the 
OPPS; however, they believed that the CCTA Category III CPT codes 
(0144T

[[Page 68039]]

through 0151T) should be moved from APCs 0282, 0376, 0377, and 0398, to 
appropriate New Technology APCs so that adequate hospital claims data 
could be gathered. They provided specific recommendations for the New 
Technology APC assignments of these services. These same commenters 
added that once CMS has acquired adequate claims data, pricing 
information could be used to separate and incorporate the various 
Category III CCTA CPT codes into clinical APCs. Some commenters were 
also concerned that CCT and CCTA procedures were not clinically 
homogeneous with other procedures currently assigned to APCs 0282, 
0376, 0377, and 0398, noting that the last three APCs previously 
contained only nuclear medicine cardiac imaging procedures.
    Response: We appreciate the suggestions submitted by the 
commenters. However, as we indicated above, some of the new Category 
III CPT codes describe services that we have determined to be similar 
in clinical characteristics and resource use to HCPCS codes in an 
existing APC. In these instances, we may assign the Category III CPT 
code to the appropriate clinical APC. In the case of these eight CCT 
and CCTA procedures, we believe that their clinical characteristics and 
resource use are similar to the other procedures assigned to APCs 0282, 
0376, 0377, and 0398. We have not limited APCs 0376, 0377, and 0398 
solely to nuclear medicine cardiac imaging services. We believe that 
cardiac imaging services using different modalities may be appropriate 
for assignment to the same clinical APCs, based on their clinical and 
resource characteristics. The OPPS is a prospective payment system that 
provides payment for services based on their assignment to APC groups, 
and, as such, we think the proposed APC assignments for these CCT and 
CCTA services, which are the same as their CY 2006 interim final 
assignments, are appropriate. While we understand that use of CCT and 
CCTA to image the heart are relatively new applications of specifically 
refined technology, cardiac imaging using other modalities is already 
well-established, as is the noncardiac use of CT and CTA. Therefore, 
for CY 2007, we are continuing with our proposal to assign Category III 
CPT codes 0144T through 0151T to clinical APCs 0282, 0376, 0377, and 
0398. We expect to have claims data for these procedures available for 
the CY 2008 OPPS update.
    After carefully considering the public comments received, we are 
finalizing our proposal without modification to assign CPT codes 0144T 
through 0151T to APCs 0282, 0376, 0377, and 0398, all with status 
indicator ``S.''
d. Radiologic Evaluation of Central Venous Access Device (APC 0340)
    For CY 2006, new CPT code 36598 (Contrast injection(s) for 
radiologic evaluation of existing central venous access device, 
including fluoroscopic guidance) was assigned to APC 0340 (Minor 
Ancillary Procedures) on an interim final basis. The proposed 
assignment of the code for CY 2007 was unchanged.
    Comment: One commenter requested that CMS assign new CPT code 36598 
to APC 0263 (Level I Miscellaneous Radiology Procedures) for CY 2007. 
The commenter stated that the procedure reported by CPT code 36598 is 
very similar to that which is coded using CPT code 76080 (Radiologic 
examination, abscess, fistula or sinus tract study, radiological 
supervision and interpretation), which is assigned to APC 0263 for CY 
2006. Further, the commenter stated that the use of contrast and 
fluoroscopy makes CPT code 36598 more resource intensive than the other 
procedures assigned to APC 0340, where CMS assigned it with an interim 
final status for CY 2006.
    Response: We will not have data upon which to base our decisions 
about the APC assignment for this procedure until next year. However, 
based on our data for many procedures that we believe are similar to 
that coded by CPT code 36598, we believe that assignment to APC 0340 is 
appropriate and do not believe that it is appropriate to reassign it to 
another APC at this time.
    We are maintaining the assignment of CPT code 36598 to APC 0340 for 
CY 2007 and will reevaluate that assignment when data become available.
2. Nuclear Medicine and Radiation Oncology Procedures
a. Myocardial Positron Emission Tomography (PET) Scans (APC 0307)
    From August 2000 to December 31, 2005, under the OPPS we assigned 
to one clinical APC all myocardial positron emission tomography (PET) 
scan procedures, which were reported with multiple G-codes through 
March 31, 2005. Effective April 1, 2005, myocardial PET scans were 
reported with three CPT codes, specifically CPT codes 78492 (Myocardial 
imaging, positron emission tomography (PET), perfusion; multiple 
studies at rest and/or stress), 78459 (Myocardial imaging, positron 
emission tomography (PET), metabolic evaluation), and 78491 (Myocardial 
imaging, positron emission tomography (PET), perfusion; single study at 
rest or stress) under the OPPS. Public comments on the CY 2006 OPPS 
proposed rule suggested that the HCPCS codes describing multiple 
myocardial PET scans should be assigned to a separate APC from single 
study codes because their hospital resource costs are significantly 
higher than single scans. Review of the CY 2004 claims data for 
myocardial PET scans revealed a median cost of $2,482 for the 9 G-codes 
that describe multiple myocardial PET scans, based upon 978 single 
claims of 2,001 total claims for multiple scan procedures. The CY 2004 
claims data showed a median cost of $800 for the 6 G-codes describing 
single PET studies, based on 391 single claims of 575 total claims. A 
review of CY 2003 claims data showed a similar pattern of significantly 
higher hospital costs for multiple myocardial PET studies in comparison 
with single studies, although there were fewer claims for the 
procedures in CY 2003 in comparison with CY 2004. In response to the 
comments received and based on this claims information, myocardial PET 
services were assigned to two clinical APCs for the CY 2006 OPPS. HCPCS 
codes for single scans were assigned to APC 0306 with a payment rate of 
$800.55, and HCPCS codes for the multiple scan procedures were assigned 
to APC 0307 (Myocardial Positron Emission Tomography (PET) Imaging) 
with a payment rate of $2,484.88.
    Analysis of the CY 2005 claims data for myocardial PET scans for 
the CY 2007 proposed rule revealed that the APC median costs for the 
single and multiple myocardial PET codes were $836 and $680 
respectively, based on 296 single claims for single studies and 1,150 
single claims for multiple scan procedures. Despite more CY 2005 single 
claims for multiple scan procedures, the median cost of these 
procedures declined significantly from CY 2004 to CY 2005, dropping 
below the median cost of single studies. As indicated earlier, there 
was a significant coding change for myocardial PET services in CY 2005, 
with the reporting of a single CPT code for multiple studies (CPT code 
78492), in comparison with nine G-codes in CY 2004. We examined the 
single bills for multiple scan procedures from CY 2004 and noted 17 
hospitals were represented, with the majority of those claims from a 
single hospital. In contrast, in the CY 2005 claims, 25 hospitals were 
represented in the single bills for multiple scan procedures, and no 
single hospital contributed a majority of claims to the median cost 
calculation. We also

[[Page 68040]]

examined differences in charges associated with G-codes versus the CPT 
code to determine if hospitals had adjusted the charge for the CPT code 
to reflect the termination of the multiple study G-codes. However, the 
individual charging practices of hospitals did not appear to vary with 
the use of a G-code versus the CPT code in either the CY 2004 or the CY 
2005 claims. Greater volume of claims and consistent charging for both 
the G-codes and CPT code by hospitals suggested that the median 
appropriately captured the greater variability in relative hospital 
costs for multiple myocardial PET studies in the CY 2005 claims data.
    Based on these claims data, we believe that it is apparent that the 
use of myocardial PET scan technology had become more widely prevalent 
in hospitals, and as a result, we had more data to support our proposed 
payment rates. We believed that the median costs from our CY 2005 
claims data for myocardial PET scan services, calculated based upon our 
standard OPPS methodology and based on almost 1,600 single claims, for 
both the single and multiple scans, were reflective of the hospital 
resources required to provide the services to Medicare beneficiaries in 
the outpatient hospital setting. Based on those data, we concluded in 
the CY 2007 proposed rule that the differential median costs of the 
single and multiple study procedures did not support the two-level APC 
payment structure. Although we acknowledged that some individuals may 
believe that multiple scan procedures should require increased 
resources at some hospitals in comparison with single scans, 
particularly because of the longer scan times required for multiple 
studies, we noted that our data did not support a resource differential 
that would necessitate the placement of these single and multiple scan 
procedures into two separate APCs. As myocardial PET scans are being 
provided more frequently at a greater number of hospitals than in the 
past, we believed that it was possible that most hospitals performing 
multiple PET scans were particularly efficient in their delivery of 
higher volumes of these services and, therefore, incurred hospital 
costs that were similar to those of single scans, which were provided 
less commonly. In fact, the CPT code for multiple scans had a lower 
median cost than either of the CPT codes for single procedures.
    When all myocardial PET scan procedure codes were combined into a 
single clinical APC, as they were prior to CY 2006, the CY 2007 
proposed rule APC median cost for myocardial PET services was about 
$727, very similar to the $703 median cost of their single CY 2005 
clinical APC. Therefore, for CY 2007, we proposed to assign CPT codes 
78459, 78491, and 78492 to a single APC, specifically, APC 0307. We 
believed that the assignment of these three CPT codes to APC 0307 was 
appropriate, as the CY 2005 claims data revealed that more hospitals 
were providing multiple myocardial PET scan services, most myocardial 
PET scans were multiple studies, and the hospital resource costs of 
single and multiple studies were similar. We believed that the proposed 
median cost appropriately reflected the hospital resources associated 
with providing myocardial PET scans to Medicare beneficiaries in cost-
efficient settings. Further, we believed that the proposed rates were 
adequate to ensure appropriate access to these services for Medicare 
beneficiaries. We specifically invited comments on our proposal to 
provide a single payment rate for all myocardial PET scans in CY 2007. 
The myocardial PET scan CPT codes and their CY 2007 proposed APC 
assignments were displayed in Table 17 of the CY 2007 OPPS proposed 
rule (71 FR 49567).
    Comment: A number of commenters requested that CMS not finalize our 
proposed APC assignments for CPT codes 78492, 78459, and 78491. The 
commenters stated that it is inappropriate to assign multiple scan 
procedures to the same APC with single scan procedures as we proposed, 
because CPT code 78492 requires more hospital resources than do CPT 
codes 78459 and 78491. The commenters stated that multiple scans 
require significantly greater hospital resources due to much longer 
scan times, and believed that our median cost data were seriously 
flawed.
    The commenters objected to the proposal to assign the multiple scan 
procedures to the same APC as the single scans because they believed 
the APC assignment creates a 2 times violation for APC 0306; the 
proposed payment for the multiple scan procedures decreases by 71 
percent between CYs 2006 and 2007; if payment is allowed to decrease to 
the level proposed by CMS, beneficiary access to these important 
diagnostic procedures (CPT code 78492) will be seriously restricted; 
the Medicare program will have to spend more for diagnostic procedures 
such as cardiac catheterizations if hospitals cannot afford to offer 
the multiple scan myocardial PET procedures; and CMS does assign other 
cardiac nuclear medicine studies to separate APCs based on whether they 
are single or multiple.
    The commenters recommended that CMS retain the multiple scan 
procedures in a separate APC as in CY 2006, and that the payment rate 
decrease be dampened to mitigate the potential for underpayment, as we 
have in the past for device-dependent and blood product APCs. One 
commenter suggested that CMS dampen payment for the multiple scans APC 
by 15 percent each year for the next 2 to 3 years to moderate the large 
payment decrease for the multiple myocardial PET scans.
    Response: We understand the commenters' objections to the median 
cost for the multiple myocardial PET scans, but see no reason to modify 
our proposal to assign them to the same APC with the single scans. We 
do not believe that our data are erroneous. Myocardial PET scans are 
not new procedures and the data across years, except for the CY 2004 
claims data, have been relatively consistent with regard to median 
costs, while the frequency of multiple scans has been growing 
consistently. As described above, we explored many aspects of the CY 
2005 claims data in an attempt to explain the decreased costs reported 
for the multiple scans and to assure ourselves and the public that the 
data were reliable. Our additional investigations included analyses of 
claims to determine whether they were submitted by only a few hospitals 
and whether any of the hospitals accounted for an unusually high number 
of the multiple scan claims or for unusually low costs. We also 
examined the claims in an attempt to detect whether there were 
differences in billing practices for the CPT code compared to the 
predecessor G-codes for multiple myocardial PET scans. There was no 
indication that the data are erroneous in any regard. Claims were 
submitted by at least 25 hospitals (compared to 17 in the CY 2004 
claims data), and no hospital was responsible for a disproportionate 
number of claims (in contrast to what was found in the CY 2004 claims) 
or for unusually low costs. No systematic hospital coding 
irregularities were discovered. Further, the number of single claims 
for the multiple scan procedures increased from 872 in the proposed 
rule data to 983 in the final rule data and the median cost remained 
stable, increasing by only $5.00, still lower than the median cost for 
single scans.
    Our data do not support a resource differential that warrants 
assignment of the multiple myocardial scan procedures to an APC 
separate from the single scans. Single and multiple scan

[[Page 68041]]

procedures are closely related from a clinical perspective, and their 
hospital resources required, as reflected in our claims data, appear 
comparable in terms of cost. The 2 times violation for CY 2007 in APC 
0307 results from the inclusion of limited data from one G-code for 
multiple scan procedures that was reported for the first 3 months of CY 
2005. The median cost for that G-code is $1,840, based on 129 single 
claims. However, the code was deleted in CY 2005, and the median cost 
for the CPT code that replaced it is only $665, based on 983 single 
claims. We utilized the data from the predecessor G-code in developing 
the median cost for APC 0307 (where it would be likely to affect the 
APC median cost by raising it). The fact that data from a deleted code 
are responsible for the violation leads us to conclude that the 
violation is not significant. Therefore, based on clinical and resource 
homogeneity, we are excepting APC 0307 from the 2 times rule for CY 
2007.
    By assigning the multiple and single scans to the same clinical APC 
for myocardial PET scans, we are maintaining the clinical and resource 
use homogeneity in APC 0307, where the APC payment will be slightly 
higher for the multiple scans than it would have been if we retained 
the multiple scans in a separate APC.
    Similarly, we do not believe that there is a basis for dampening 
the payment decrease for a separate multiple myocardial PET scan APC. 
Although we have adjusted payment amounts for device-dependent and 
blood product APCs in the past, as noted by the commenters, we 
generally have done so to moderate the effects on payment resulting 
from inaccurate claims data that failed to fully capture the costs 
associated with the procedures in ways that we could partially 
identify. In some of these situations, we had very few single claims, 
contributing to the problem of unstable payment rates, but myocardial 
PET scans have significant numbers of single claims. We have examined 
the claims data thoroughly and found nothing to indicate inaccuracy for 
myocardial PET scans. To the contrary, with the exception of the CY 
2004 claims data, we found that costs from the CY 2005 claims are 
relatively consistent with costs calculated from claims for myocardial 
PET scans provided in years before CY 2004. We believe that our CY 2006 
APC assignments for multiple and single myocardial PET scans to 
separate APCs were based on data that were unduly affected by one 
hospital's unusually high charges for multiple scans.
    Without evidence that the claims data for CPT codes 78459, 78491, 
and 78492 are too flawed to use as a basis for setting weights, we 
believe it is prudent to establish the CY 2007 payment rate for APC 
0307 using the standard OPPS methodology for developing payment rates.
    After carefully considering the public comments received, we are 
finalizing the APC assignments for the myocardial PET procedures as 
shown in Table 12 below without modification.

                              Table 12.--CY 2007 APC Assignment for Myocardial PET
----------------------------------------------------------------------------------------------------------------
                                                                                                  CY 2007  Final
            HCPCS code                 Short descriptor      CY 2007    CY 2007       CY 2007        APC  307
                                                               SI         APC       median cost     median cost
----------------------------------------------------------------------------------------------------------------
78459.............................  Heart muscle imaging           S        0307         $784.42         $726.98
                                     (PET).
78491.............................  Heart image (pet),             S        0307        1,014.61          726.98
                                     single.
78492.............................  Heart image (pet),             S        0307          665.42          726.98
                                     multiple.
----------------------------------------------------------------------------------------------------------------

b. Complex Interstitial Radiation Source Application (APC 0651)
    APC 0651 (Complex Interstitial Radiation Source Application) 
contains only one code, CPT code 77778 (Complex interstitial 
application of brachytherapy sources). The coding, APC assignment, 
median cost, and resulting payment rate for CPT code 77778 have not 
been stable since the inception of the OPPS, and that instability has 
been a source of concern to hospitals that furnish the service and to 
specialty societies. The vast majority of claims for interstitial 
brachytherapy are for the treatment of patients with a diagnosis of 
prostate cancer. The historical coding, APC assignments, and payment 
rates for CPT code 77778 and the related service CPT code 55859 
(Transperitoneal placement of needles or catheters into the prostate 
for application of brachytherapy sources) were displayed in Table 14 of 
the CY 2007 OPPS proposed rule (71 FR 49564), and are reproduced below 
in Table 13.
BILLING CODE 4120-01-P

[[Page 68042]]

[GRAPHIC] [TIFF OMITTED] TR24NO06.016

BILLING CODE 4120-01-C

    We have frequently been informed by the public that the instability 
in our payment rates for APC 0651 creates difficulty in planning and 
budgeting for hospitals. Moreover, we have been informed that, in this 
case, reliance on single procedure claims results in use of only 
incorrectly coded claims for prostate brachytherapy because, for 
application to the prostate, which is estimated to be 85 percent of all 
occurrences of CPT code 77778, a correctly coded claim is a multiple 
procedure claim. Specifically, we have been advised that a correctly 
coded claim for prostate brachytherapy should include, for the same 
date of service, both CPT codes 55859 and 77778, brachytherapy sources 
reported with C-codes, and typically separately coded imaging and 
radiation therapy planning services. We have been further advised that, 
in the cases of complex interstitial brachytherapy where sources are 
placed in sites other than the prostate, the charges for both placing 
the needles or catheters and for applying the sources may be reported 
by CPT code 77778 alone because there are no other specific CPT codes 
for placement of needles or catheters in those sites. In other cases, 
the placement of needles or catheters may be reported with not 
otherwise classified codes specific to the treated body area.
    At the March 2006 APC Panel meeting, presenters urged the Panel to 
recommend that CMS use only single procedure claims that contained 
charges for brachytherapy sources on the same claim with CPT code 77778 
to set the median cost for APC 0651. Presenters also urged that CMS 
adopt a process for using multiple procedure claims to set the median 
for APC 0651 that would sum the costs on multiple procedure claims 
containing CPT codes 77778 and 55859 (and no other separately payable 
services not on the bypass list) and, excluding the costs of sources, 
split the resulting aggregate median cost on the multiple procedure 
claim according to a preestablished attribution ratio between CPT codes 
77778 and 55859. The presenters also urged CMS to provide hospitals 
with education on correct coding of brachytherapy services and devices 
of brachytherapy required to perform brachytherapy procedures. They 
indicated that any claim for a brachytherapy service that did not also 
report a brachytherapy source should be considered to be incorrectly 
coded and thus not reflective of the hospital's resources required for 
the interstitial source application procedure. The presenters believed 
that these claims should be excluded from use in establishing the 
median cost for APC 0651. They believed that hospitals that reported 
the brachytherapy sources on their claims were more likely to report 
complete charges for the associated brachytherapy procedure than 
hospitals that did not report the separately payable brachytherapy 
sources.
    The APC Panel recommended that CMS reevaluate the proposed payment 
for brachytherapy services in APC 0651 for CY 2007. The APC Panel also 
recommended that CMS formally work with the Coalition for the 
Advancement of Brachytherapy, the American Brachytherapy Society, and 
the American Society for Therapeutic Radiology and Oncology to evaluate 
the methodology for setting brachytherapy service payment rates in APC 
0651.
    In response to the APC Panel recommendations, we explicitly 
analyzed the standard OPPS methodology that we used in determining our 
CY 2007 proposed payment rate for APC 0651 in the context of 
alternative multiple bill methodologies.
    The organizations that the APC Panel asked us to work with have 
frequently brought their concerns to our attention through the 
rulemaking process and otherwise. As stated in the CY 2007 OPPS 
proposed rule, we will consider the input of any individual or 
organization to the extent allowed by Federal law, including the 
Administrative Procedure Act (APA)

[[Page 68043]]

and the Federal Advisory Committee Act (FACA) (71 FR 49564).
    We establish the OPPS rates through regulations. We are required to 
consider the timely comments of interested organizations, establish the 
payment policies for the forthcoming year, and respond to the timely 
comments of all public commenters in the final rule in which we 
establish the payments for the forthcoming year.
    For the CY 2007 OPPS proposed rule, we developed a median cost for 
APC 0651 using single procedure claims and the general OPPS 
methodology, but we also looked at multiple procedure claims that 
contained the most common combinations of codes used with APC 0651. In 
the proposed rule, our single procedure claims process using CY 2005 
data resulted in using 1,123 claims to calculate a proposed median cost 
of $1,028.93 for APC 0651. We added CPT code 76965, a CPT code for 
ultrasound guidance that commonly appeared on claims for complex 
interstitial brachytherapy, to the bypass list for CY 2007 after close 
clinical review because we believed that it would typically have little 
associated packaging. We believed that this change, along with 
maintenance of CPT code 77290 for complex therapeutic radiology 
simulation-aided field setting on the bypass list, was responsible for 
the growth in single procedure claims from the 381 single bills upon 
which the final APC 0651 median cost was calculated for CY 2006. 
However, only 6 of these 1,123 single and ``pseudo'' single claims data 
used in calculating the proposed median cost also included 
brachytherapy sources used in complex interstitial brachytherapy source 
application, and the median cost for these 6 claims at $600.68 was 
significantly less than the median cost for all single claims. It was 
unclear why so many of these claims did not contain brachytherapy 
sources, which were separately paid at cost in CY 2005. Because we 
proposed to pay separately for brachytherapy sources again for CY 2007, 
we saw no reason to believe that these few claims for brachytherapy 
services that included sources, which also did not report CPT code 
55859 for placement of needles or catheters into the prostate, were 
more correctly coded than those claims that did not separately report 
brachytherapy sources. We believed it was possible that hospitals 
billing CPT code 77778 and not the associated brachytherapy sources may 
have bundled their charges for the brachytherapy sources into their 
charge for CPT code 77778.
    We also identified multiple procedure claims that contained both 
CPT codes 55859 and 77778 and also included any one or more of the 
following procedure codes, which have repeatedly appeared as common 
procedures that are reported on the same claim with CPT codes 55859 and 
77778: 76000, 76965, or 77290. We then calculated median costs for 
interstitial prostate brachytherapy in two different ways: (1) 
Bypassing the line item charges for these three ancillary codes; and 
(2) packaging the costs of these three ancillary codes. We applied this 
methodology both (1) to all claims that met these criteria with and 
without sources; and (2) to claims that met the criteria and also 
separately reported brachytherapy sources that would be expected to be 
reported with CPT code 77778. See Tables 15 and 16 published in the CY 
2007 OPPS proposed rule (71 FR 49565) and shown below as Table 14-A and 
Table 14-B for the results of this investigation.
    In the proposed rule, we found 10,571 multiple procedure claims 
with CPT codes 55859 and 77778 reported on the claim, including those 
both with and without separately reported sources. We found that 7,181 
of the 10,571 claims in the proposed rule's data contained any 
combination of the three ancillary codes (76000, 76965, or 77290). 
Table 14-A shows the results of bypassing and packaging the line-item 
costs of the three ancillary procedures based on the data used to 
construct the proposed rule.

          Table 14-A.--Multiple Procedure Claims Including CPT Codes 55859 and 77778 Proposed Rule Data
----------------------------------------------------------------------------------------------------------------
                                                                Minimum      Maximum
                                             Frequency            cost         cost      Mean cost   Median cost
----------------------------------------------------------------------------------------------------------------
Ancillary Codes Packaged............  7180 (1 lost to             $828.46   $11,202.81    $3,326.50    $3,062.99
                                       trimming).
Ancillary Codes Bypassed............  7181..................       811.95    11,203.81     3,300.16     3,030.01
----------------------------------------------------------------------------------------------------------------

    We found 9,791 multiple procedure claims in the proposed rule's 
data with CPT codes 55859 and 77778 reported on the claim that also 
included brachytherapy sources that would be used with CPT code 77778. 
We found that 6,748 of the 9,791 claims contained any combination of 
the three ancillary codes. Table 14-B shows the results of bypassing 
and packaging the line-item costs of the three ancillary procedures, 
using the proposed rule's data.

    Table 14-B.--Multiple Procedure Claims Including CPT codes 55859 and 77778 and One or More Brachytherapy
                                           Sources--Proposed Rule Data
----------------------------------------------------------------------------------------------------------------
                                                                 Minimum      Maximum                   Median
                                                   Frequency      cost         cost      Mean  cost      cost
----------------------------------------------------------------------------------------------------------------
Ancillary Codes Packaged.......................        6,748      $890.56   $10,224.17    $3,240.13    $3,026.62
Ancillary Codes Bypassed.......................        6,748      $912.81   $10,307.37    $3,215.75    $2,992.60
----------------------------------------------------------------------------------------------------------------

    We found that the claims containing CPT codes 55859 and 77778 and 
any combination of the three identified ancillary codes had mean and 
median costs that were very close to one another, regardless of whether 
the hospital billed separately for the brachytherapy sources on the 
claim with the procedure codes. Moreover, most of the multiple 
procedure claims we identified contained sources. This led us to 
conclude that the presence of sources on the claim did not make a 
significant difference in the median cost of the combined service.
    Moreover, when we calculated the total median cost from single 
bills for the APCs for the two major procedures codes from the proposed 
rule's data without regard to the separate payments that would be made 
for CPT codes 76000, 76965, and 77290, the sum of the CY 2007 proposed 
medians for APC

[[Page 68044]]

0651 and APC 0163 was $3,197.07, which was greater than the combination 
medians, even when the three ancillary services were packaged into the 
combination median. Under our proposed policies for CY 2007, hospitals 
would also be paid separately for brachytherapy sources, guidance 
services, and radiation therapy planning services that may be provided 
in support of services reported with CPT codes 55859 and 77778.
    Therefore, as indicated in the CY 2007 OPPS proposed rule (71 FR 
49565), we believed that the summed median cost for APC 0651 and APC 
0163 results in an appropriate level of full payment for the dominant 
type of service provided under APC 0651, interstitial prostate 
brachytherapy. We proposed to use the median cost of $1,028.93, as 
derived from all single bills for APC 0651 according to our standard 
OPPS methodology, to establish the median for that APC.
    We recognized that prostate brachytherapy was not the sole use of 
CPT code 77778, although it was the predominant use. Costs attributable 
to the placement of needles and catheters and to the interstitial 
application of brachytherapy sources to sites other than the prostate 
may also be reported on claims whose data map to APC 0651. As we noted 
in the proposed rule, this clinically driven variability in the claims 
data was difficult to assess without adding additional levels of 
complexity to the issue by considering diagnoses in establishing 
payments rates. However, recognizing that a prospective payment system 
is a system based on averages and, to the extent that claims for all 
types of complex interstitial brachytherapy source application were 
included in the body of claims used to set the median cost for APC 
0651, we believed that the payment for these services as proposed for 
CY 2007 was appropriate.
    We received several public comments concerning our proposal. A 
summary of the comments and our responses follow:
    Comment: The commenters generally supported the proposed median 
cost for APC 0651. One commenter encouraged CMS to consider calculating 
a packaged combination median cost for both CPT codes 55859 and 77778 
and splitting the cost between the two codes, should the median cost 
for APC 0651 drop by a significant percent in future years as it has 
sometimes done in the past.
    Response: The median cost for APC 0651 calculated using CY 2005 
claims data as updated for this final rule with comment period is 
$1,029.47, virtually the same as the proposed rule median cost of 
$1,028.93. Together with the median cost for APC 0163 of $2,134.32, and 
separate payment for each source applied (section VII. of this 
preamble), we believe that the OPPS will make appropriate payment for 
brachytherapy services in CY 2007.
    After carefully considering the public comments received, we are 
finalizing our proposal to develop a median cost for APC 0651 using 
single procedure claims and the general OPPS methodology as discussed 
above without modification.
c. Proton Beam Therapy (APCs 0664 and 0667)
    For CY 2007, we proposed to pay for the following four CPT codes 
that describe proton beam therapy: 77520 (Proton treatment delivery; 
simple, without compensation), 77522 (Proton treatment delivery; 
simple, with compensation), 77523 (Proton treatment delivery; 
intermediate), and 77525 (Proton treatment delivery; complex). We 
proposed to assign the simple proton beam therapy procedures to APC 
0664 (Level I Proton Beam Radiation Therapy), with a proposed median 
cost of $1,141, and the intermediate and complex proton beam therapy 
procedures to APC 0667 (Level II Proton Beam Radiation Therapy), with a 
proposed median cost of $1,365. These proposed assignments were 
unchanged from CY 2006. The proposed payment rates for proton beam 
therapy were based on CY 2005 claims data and showed an increase of 
about 20 percent over the CY 2006 payment rates.
    Comment: Several commenters supported our CY 2007 proposed APC 
assignments and payment rates for proton beam therapy. The commenters 
also supported our proposing APC 0664 as an exception to the 2 times 
rule for CY 2007. They were generally concerned about the payment for 
the same services furnished in freestanding proton therapy centers 
located in several States because the OPPS payment rates were very 
different from the carrier-priced payments for these services. The 
commenters requested that CMS establish consistent payments for these 
services under the OPPS and the MPFS because the significant capital 
costs required to provide proton beam therapy treatments do not vary 
across delivery settings.
    Response: We appreciate the commenters' support for our CY 2007 
OPPS proposed payment rates for proton therapy. We note that the OPPS 
payment rates for these services have increased significantly over the 
past several years, although we understand that there are only a small 
number of active hospital-based centers providing proton therapy. In 
addition, this is the second year in which we have exempted APC 0664 
from its violation of the 2 times rule. We also observe that the 
payment rates for the two proton therapy APCs are quite close for CY 
2007, with only a small differential between Levels I and II of 
therapy. As such, we will continue to monitor our claims data for 
proton beam therapy in the future to assess the appropriateness of the 
current APC structure. We are generally concerned about APCs that 
chronically violate the 2 times rule, especially when those APCs 
contain few services and we have no specific data concerns regarding 
the services assigned to them.
    With respect to the commenters' request regarding consistent 
payment for proton therapy under the MPFS and the OPPS, we note the 
MPFS and the OPPS are completely separate payment systems, whose rates 
are established based on different methodologies.
    After careful consideration of the public comments received, we are 
finalizing without modification our CY 2007 proposal to provide payment 
for proton beam therapy through APCs 0664 and 0667, with their payment 
rates based on the final APC median costs of $1,154 and $1,381, 
respectively.
d. Urinary Bladder Residual Study (APC 0340)
    At its February 2005 meeting, the APC Panel recommended that we 
move CPT code 78730 (Urinary bladder residual study) from APC 0340 
(Minor Ancillary Procedures) to APC 0404 (Level I Renal and 
Genitourinary Studies) for CY 2006, because the Panel believed that the 
CY 2003 data for CPT code 78730 may have been derived from incorrectly 
coded hospital claims. Based on reasons discussed in detail in the CY 
2006 OPPS final rule with comment period (70 FR 68602), we maintained 
the assignment of CPT code 78730 in APC 0340 for CY 2006. For CY 2007, 
we proposed assignment of CPT code 78370 to APC 0340 once again.
    Comment: Several commenters requested that CMS move CPT code 78730 
from APC 0340 to APC 0399 (Nuclear Medicine Add-on Imaging). Some 
commenters indicated that in CY 2005 they disagreed with our APC 
assignment of APC 0340 for CPT code 78730. One commenter added that the 
data for CPT code 78730 may have been derived from incorrectly coded 
hospital claims. The commenters indicated that the CPT Editorial Panel 
would be revising the service's code descriptor for CY 2007 to more 
specifically indicate the performance of a nuclear medicine procedure.

[[Page 68045]]

    Response: In the November 15, 2004 final rule with comment period 
(69 FR 65705), we stated that CPT code 78730 was originally created and 
valued for the MPFS as a procedure requiring the services of a nuclear 
medicine technician, but that the use of the code subsequently had 
changed to be used primarily by urologists rather than by nuclear 
medicine physicians. While we reassigned CPT code 78730 to APC 0340 for 
CY 2005 based on robust CY 2003 claims data, we solicited other 
physician specialties to submit resource data for us to review in the 
context of our hospital claims data so that we could reexamine the 
appropriate APC placement of CPT code 78730 for CY 2006. While we 
acknowledge the commenters' repeated concern that the median cost for 
CPT code 78730 may reflect miscoded claims, commenters again provided 
no supporting evidence for either CY 2006 or CY 2007 of what they 
believe to be the true resource costs associated with CPT code 78730. 
In fact, a relatively stable number of single procedure claims has 
generated a consistent median cost for CPT code 78730 over the past 5 
years (that is, ranging from $39 based on the CY 2001 claims data to 
$42 based on the CY 2005 claims data) and supports our assignment of 
CPT code 78730 to APC 0340 with an APC median cost of $37, as opposed 
to APC 0399 with an APC median cost of $92. We are aware that the code 
descriptor and parenthetical language in the CPT manual for CPT code 
78730 indicating other CPT codes to be reported for certain bladder 
studies will be modified for CY 2007. However, we do not know if these 
additional instructions will lead to differences in hospital reporting 
that result in a significant change in the procedure's cost. Therefore, 
we are maintaining CPT code 78730 in APC 0340 for CY 2007.
    After carefully considering the public comments received, we are 
finalizing our proposal to assign CPT code 78730 to APC 0340 for CY 
2007, with a median cost of $37.29.
e. Hyperthermia Treatment (APC 0314)
    We did not propose any APC assignment changes for CY 2007 for the 
CPT codes used to report hyperthermia treatments. The following five 
hyperthermia treatment CPT codes are the only codes that we proposed to 
assign to APC 0314 (Hyperthermic Therapies) for CY 2007: 77600 
(Hyperthermia, externally generated; superficial); 77605 (Hyperthermia, 
externally generated; deep); 77610 (Hyperthermia, generated by 
interstitial probe(s); 5 or fewer interstitial applicators); 77615 
(Hyperthermia, generated by interstitial probe(s) more than 5 
interstitial applicators); and 77620 (Hyperthermia generated by 
intracavitary probe(s)). The CY 2007 proposed median cost for APC 0314 
was $225.96.
    Comment: Several commenters reported that the proposed APC 0314 CY 
2007 payment rate was 32 percent less than the CY 2006 payment rate of 
$332.31 and suggested that the decrease was due to the use of 
inaccurate CMS claims data.
    The commenters believed that the flaws in the CMS claims data were 
due to a few factors: The variation in hospitals' cost allocation 
methodologies; CMS' use of hospital CCRs derived from those varying 
hospital allocation practices and which they reported varied 
dramatically (from 15 to 50 percent) across hospitals that provided 
hyperthermia therapies; and low utilization among the few hospitals 
that reported the services. Further, the commenters expressed an 
additional concern for one of the procedures, CPT code 77605, for which 
there were no claims in the CY 2005 data that CMS used for the CY 2007 
median calculation proposal. The commenters added that in past years, 
the procedure had been one of the more frequently reported therapies, 
and they believed that having no cases in the claims data used to 
calculate the medians for APC 0314 was indicative of inaccurate data 
and also contributed to the inappropriately low proposed median cost.
    The commenters submitted some estimated hospital costs of 
hyperthermia treatment for five hospitals, and recommended three 
options that CMS could use to moderate the proposed CY 2007 payment 
decrease for APC 0314. The three options are as follows: That CMS could 
use external hospital survey data to establish a payment rate of $1,005 
for APC 0314; that CMS could apply an average cost for CPT code 77605 
using the medians calculated for CY 2004 through CY 2006 to establish a 
more appropriate payment amount for CY 2007; or that CMS could maintain 
the CY 2006 payment rate for CY 2007.
    Response: In our analysis, we found that there were 55 claims 
reported for CPT code 77605 in the CY 2005 data, but that all were 
excluded from the data because they did not meet the criteria for use 
in calculating the median costs due to any number of factors. Included 
among the reasons for removing the claims for CPT 77605 from the CY 
2005 data that were used to calculate median costs were that the 
reporting hospitals' claims were excluded because their CCRs were 
outside of the allowed range, or the reporting hospital was a CAH or an 
otherwise excluded hospital (as explained in section II. of this final 
rule with comment period).
    We exclude claims from the data to be used for calculation of 
median costs every year to ensure that the claims we use are accurate 
and valid representations of claims for the services. The method for 
identifying claims that meet the criteria for inclusion in the median 
cost development process for CY 2007 was performed similarly to the 
methodology applied for past OPPS updates and should not have had a 
disproportionate effect on hyperthermia procedures.
    As noted by the commenters, median costs for the hyperthermia 
procedures have been somewhat unstable across the years due to low 
volume and the small number of facilities reporting the procedures. For 
CY 2007, the decrease is more pronounced than changes in past years and 
we appreciate the providers' concerns. We note that these historical 
changes have served both to increase and decrease payments for the 
treatments over time. We agree with the commenters' observation about 
the relative median cost instability for these procedures and the 
probable reasons for that, but given that we do not observe specific 
inaccuracies in our claims data that are used in the standard OPPS 
methodology, it appears these fluctuations are in keeping with the 
historical charges.
    The median costs for the individual procedures assigned to APC 0314 
vary from approximately $194 to $431. The median for the APC overall is 
significantly lower than the highest service-specific median because 
195 of the 225 single claims for the APC are for CPT code 77600, which 
has a median cost of $194. In the past, CPT code 77605 has contributed 
a significant number of claims to the number of single claims in the 
APC and has also had a higher median than CPT 77600. Thus, the lack of 
claims for that procedure may have contributed to the lower APC median 
for CY 2007, but the median cost calculated for the APC is accurate and 
reflects costs for those services based upon the CY 2005 claims data 
that meet our criteria for use in calculating APC medians. We have no 
reason to doubt the accuracy of those data and, therefore, have no 
basis for diverging from the established method of calculating the 
median cost for APC 0314.
    For these reasons, we will not accept any of the options 
recommended to us by the commenters and are finalizing the CY 2007 
payment rate for APC 0314

[[Page 68046]]

based on its median cost of $204, calculated using our CY 2005 claims 
data as proposed.
f. Unlisted Procedure for Clinical Brachytherapy (APC 0312)
    For CY 2007, we proposed to move CPT code 77799 (Unlisted 
procedure, clinical brachytherapy) from APC 0313 (Brachytherapy) to APC 
0312 (Radioelement Applications) for the CY 2007 OPPS.
    Comment: Several commenters objected to the proposal to reassign 
CPT code 77799 from APC 0313 to APC 0312 for CY 2007. The commenters 
stated that APC 0312 is titled ``Radioelement Applications,'' while APC 
0313 is titled ``Brachytherapy,'' and that it is in keeping with the 
intent of APC classification to group procedures that are similar in 
clinical characteristics and resource use. Therefore, the commenters 
believed that because APC 0313 was the lowest payment level 
brachytherapy APC, it would be most appropriate to continue to assign 
CPT code 77799 to APC 0313 with other brachytherapy procedures.
    Response: We disagree. CPT code 77799 has no meaningful definition 
that would enable us to place it accurately in one brachytherapy APC 
versus another APC based on clinical homogeneity or resource 
considerations. While the APC title for APC 0312 does not contain the 
term brachytherapy explicitly, all of the procedures assigned to APC 
0312 are from the section of the CPT manual called ``Clinical 
Brachytherapy.'' Furthermore, APC 0312, not APC 0313, is the lowest 
payment level brachytherapy procedure APC. In CY 2005, we finalized the 
OPPS policy of assigning all unlisted or ``not otherwise classified'' 
HCPCS codes to the lowest level APC that is appropriate to the clinical 
nature of the service (69 FR 65725). Therefore, we believe that our 
reassignment of CPT code 77799 to APC 0312 is appropriate.
    After carefully considering the public comments received, we are 
finalizing our CY 2007 proposal for the assignment of CPT code 77799 to 
APC 0312, without modification.
3. Cardiac and Vascular Procedures
a. Electrophysiologic Recording/Mapping (APC 0087)
    At its March 2006 meeting, the APC Panel heard testimony from a 
presenter who asked that the Panel recommend that CPT codes 93609 
(Intraventricular and/or intra-atrial mapping of tachycardia, add-on); 
93613 (Intracardiac electrophysiologic 3-D mapping); and 93631 (Intra-
operative epicardial and endocardial pacing and mapping to localize 
zone of slow conduction for surgical correction) be removed from APC 
0087. The presenter asked the APC Panel to recommend that these codes 
be placed in APC 0086 (Ablate Heart Dysrhythm Focus) for improved 
clinical and resource alignment. The presenter indicated that the 
median costs for these CPT codes were more than two times the median 
cost of the least costly HCPCS code in APC 0087 and, therefore, 
constituted a 2 times rule violation. The presenter also indicated that 
the median cost of APC 0087 had declined in recent years, and argued 
that the payment rate for APC 0087 was too low to adequately compensate 
providers for these services.
    The APC Panel did not recommend that CMS move these codes from APC 
0087 to APC 0086, but instead recommended that CMS maintain the three 
codes in APC 0087 for CY 2007. The APC Panel noted that, due to the low 
volume of these and other services assigned to APC 0087, under the CMS' 
rules there was no 2 times violation in APC 0087. Moreover, the APC 
Panel found that the services under discussion were cardiac 
electrophysiologic mapping services like other procedures also assigned 
to APC 0087, and were, therefore, clinically coherent with other 
services in APC 0087. The APC Panel did not believe that these three 
cardiac electrophysiologic mapping procedures were similar clinically 
or from a resource perspective to the intracardiac catheter ablation 
procedures residing in APC 0086. We agreed with the APC Panel's 
assessment and accepted this APC Panel recommendation. Therefore, we 
proposed that CPT codes 93609, 93613, and 93631 remain assigned to APC 
0087 for CY 2007.
    We did not receive any public comments concerning our proposal. 
Therefore, we are adopting our CY 2007 proposal as final without 
modification.
b. Endovenous Laser Ablation Procedures (APC 0092)
    We proposed to reassign CPT codes 36478 (Endovenous ablation 
therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous laser; first vein treated;) and 
36479 (Endovenous ablation therapy of incompetent vein, extremity, 
inclusive of all imaging guidance and monitoring, percutaneous laser; 
second and subsequent veins treated in a single extremity, each through 
separate access sites) from APC 0091 (Level II Vascular Ligation) for 
CY 2007 to APC 0092 (Level I Vascular Ligation), with a proposed median 
cost of $1,518.22 for CY 2007.
    Comment: A few commenters requested that CMS retain CPT codes 36478 
and 36479 in APC 0091 for CY 2007 instead of assigning them to APC 
0092, as we proposed. The commenters believed that the percutaneous 
laser procedures should be assigned to the same APC as CPT codes 36475 
(Endovenous ablation therapy of incompetent vein, extremity, inclusive 
of all imaging guidance and monitoring, percutaneous, radiofrequency; 
first vein treated); and 36476 (Endovenous ablation therapy of 
incompetent vein, extremity, inclusive of all imaging guidance and 
monitoring, percutaneous, radiofrequency; second and subsequent veins 
treated in a single extremity, each through separate access sites), 
because the hospital costs for both types of procedures are very 
similar. The proposed APC assignment for CPT codes 36475 and 36476 was 
to APC 0091.
    Response: In our review of APCs for the CY 2007 proposed rule, we 
found that the procedures assigned to APCs 0091 and 0092 were 
appropriate clinically, but that the median costs within both of the 
APCs had become heterogeneous so there was not significant 
differentiation between the medians for the two levels of vascular 
APCs. In addition, CPT codes 36475 through 36479 were new in CY 2005 
and, as such, their median costs were available to us for the first 
time in our development of the CY 2007 proposed rule.
    In order to remedy the heterogeneity within APCs 0091 and 0092, we 
reconfigured them to achieve greater differentiation between the median 
costs of the two APCs and to improve internal homogeneity. In that 
reconfiguration, CPT codes 36478 and 36479 were assigned to APC 0092, 
with other procedures with similar resource requirements. The median 
costs for CPT codes 36478 and 36479 are $1,521 and $1,241, 
respectively, and the median cost for APC 0092 is $1,520. There are 
more than 800 single claims for CPT code 36478, and we are confident 
that the data reflect hospital costs for the procedure. We believe that 
these procedures fit appropriately into the APC 0092.
    In contrast, CPT codes 36475 and 36476 were assigned to APC 0091, 
which has a median cost of $2,122. The median costs for those 
procedures are $2,295 and $3,017, respectively, and there are more than 
900 single claims for CPT code 36475. Although the endovenous ablation 
procedures described by CPT codes 34675 through 36479 are clinically 
related, we do not believe that they belong in the same

[[Page 68047]]

APC. In this case, there exist separate APCs into which each procedure 
type is appropriately assigned to reflect more similar usage.
    The reconfiguration resulted in improved differentiation between 
the two APCs. For CY 2006, the difference between the APC median costs 
was only about $140. For CY 2007, that difference is about $600, and 
the internal homogeneity in each APC is improved.
    For these reasons we are finalizing our proposal to assign CPT 
codes 36478 and 36479 to APC 0092 for CY 2007.
c. Repair/Repositioning of Defibrillator Leads (APC 0106)
    For CY 2007, we proposed to assign CPT code 33218 (Repair of single 
transvenous electrode for a single chamber, permanent pacemaker or 
single chamber pacing cardioverter-defibrillator), and CPT code 33220 
(Repair of two transvenous electrodes for a dual chamber permanent 
pacemaker or dual chamber pacing cardioverter-defibrillator) to APC 
0106 (Insertion/Replacement/Repair of Pacemaker and/or Electrodes), 
with a proposed median cost of $2,754.86. These procedures were both 
assigned to APC 0106 for CY 2006.
    Comment: Several commenters asked CMS to reassign CPT codes 33218 
and 33220 from APC 0106 to APC 0105 (Revision/Removal of Pacemakers, 
AICD, or Vascular Devices) because these two codes do not require a 
device like other codes in APC 0106 and their median costs are closer 
to the proposed median cost of APC 0105 of $1,449.44.
    Response: We agree and have moved CPT codes 33218 and 33220 out of 
APC 0106 and into APC 0105 for CY 2007. The final rule median cost for 
APC 0106 is $3,596.86.
    After carefully considering the public comments received, we are 
finalizing our CY 2007 proposal with modification to reassign CPT codes 
33218 and 33220 from APC 0106 to APC 0105. We also are modifying the 
titles of these APCs to reflect their new composition. APC 0106 is 
retitled ``Insertion/Replacement of Pacemaker Leads and/or 
Electrodes.'' APC 0105 is retitled ``Repair/Revision/Removal of 
Pacemakers, AICDs, or Vascular Devices.'' The final median cost of APC 
0106 is $3,596.87, and the final median cost of APC 0105 is $1,565.27.
d. Thrombectomy Procedures (APCs 0103 and 0653)
    For CY 2006, new CPT codes 37184 (Primary percutaneous transluminal 
mechanical thrombectomy, noncoronary, arterial or arterial bypass 
graft, including fluoroscopic guidance and intraprocedural 
pharmacological thrombolytic injection(s); initial vessel); 37187 
(Percutaneous transluminal mechanical thrombectomy, vein(s), including 
intraprocedural pharmacological thrombolytic injection(s) and 
fluoroscopic guidance); and 37188 (Percutaneous transluminal mechanical 
thrombectomy, vein(s), including intraprocedural pharmacological 
thrombolytic injection(s) and fluoroscopic guidance, repeat treatment 
on subsequent day during course of thrombolytic therapy) were provided 
interim final assignments to APC 0653 (Vascular Reconstruction/Fistula 
Repair with Device). New CPT codes 37185 (Primary percutaneous 
transluminal mechanical thrombectomy, noncoronary, arterial or arterial 
bypass graft, including fluoroscopic guidance and intraprocedural 
pharmacological thrombolytic injection(s); second and all subsequent 
vessel(s) within the same vascular family) and 37186 (Secondary 
percutaneous transluminal thrombectomy (e.g., nonprimary mechanical, 
snare basket, suction technique), noncoronary, arterial or arterial 
bypass graft, including fluoroscopic guidance and intraprocedural 
pharmacological thrombolytic injections, provided in conjunction with 
another percutaneous intervention other than primary mechanical 
thrombectomy) were provided interim final assignments to APC 0103 
(Miscellaneous Vascular Procedures). The proposed assignments of these 
codes for CY 2007 were unchanged.
    Comment: One commenter who addressed our CY 2006 APC assignments 
for CPT codes 37184, 37187, and 37188 believed that all of the new 
codes should have been assigned to APC 0088 (Thrombectomy). The 
commenter stated that the procedures reported by the new CPT codes were 
very similar to the procedures reported by CPT code 92973 (Percutaneous 
transluminal coronary thrombectomy), that was assigned to APC 0088 
because they required the use of a costly mechanical thrombectomy 
catheter. The commenter stated that the procedures coded with CPT codes 
37184 through 37188 also required the use of costly catheters and were 
clinically more similar to the other procedures assigned to APC 0088 
than to those assigned to either APC 0103 or APC 0653.
    Response: Although we will not have data for these procedures until 
next year, based on the information in the comment and our further 
review, we agree with the commenter that a more appropriate assignment 
for the procedures is APC 0088 for CY 2007. We believe the 
reassignments provide more accurate payment for these thrombectomy 
procedures.
    After careful consideration of the public comment received, we are 
finalizing our proposal for the APC assignments of CPT codes 37184, 
37185, 37186, 37187, and 37188 with modification. All five procedures 
are assigned to APC 0088 for CY 2007.
4. Gastrointestinal and Genitourinary Procedures
a. Insertion of Mesh or Other Prosthesis (APC 0195)
    During the March 2006 APC Panel meeting, a presenter requested that 
we reassign CPT code 57267 (Insertion of mesh or other prosthesis for 
repair of pelvic floor defect, each site (anterior, posterior 
compartment), vaginal approach) to a more clinically and resource-
appropriate APC than its CY 2006 assignment to APC 0154 (Hernia/
Hydrocele Procedures). The presenter expressed concern that the 
procedure was currently assigned to an APC with a ``T'' status 
indicator and stated that payment would be more accurate if it were 
assigned to an APC that has an ``S'' status indicator. The mesh 
insertion procedure is a CPT add-on code and is, by definition, 
performed at the same time as certain other procedures and will, 
therefore, be discounted every time it is performed. The presenter 
objected to our assignment of CPT code 57267 to an APC that was subject 
to the multiple procedure discount because it was always a secondary 
procedure, and the discounted payment amount was not adequate to pay 
even for the cost of the implantable mesh. The presenter also believed 
that its assignment to an APC where hernia and hydrocele procedures 
were also assigned was clinically inappropriate.
    The APC Panel recommended that CMS reassign CPT code 57267 to a 
more clinically and resource-appropriate APC.
    As stated in the CY 2007 OPPS proposed rule, in the CY 2005 claims 
data, the median cost for CPT code 57267 was $529.14, the lowest by far 
for procedures in APC 0154, which had a proposed APC median cost of 
$1,821 for CY 2007 (71 FR 49562). However, the proposed median cost of 
CPT code 57267 was based on only 6 single claims of the total 1,038 
claims submitted for the service. Because the procedure always was 
performed in addition to other related procedures, we expected that 
claims for this service would be multiple claims. Therefore, we were 
not confident that the procedure's median

[[Page 68048]]

cost based upon the six single claims was accurate.
    Therefore, at the time of the proposed rule, in order to obtain 
more information about the cost of the procedure, we performed 
additional analyses of CY 2005 claims data in an attempt to 
specifically explore the cost of the mesh implant packaged into the 
payment for CPT code 57267. We believe that a significant portion of 
the procedural cost should be related to the cost of the mesh, based on 
information presented at the March 2006 APC Panel meeting. We looked at 
all claims that included charges for the HCPCS code for implantable 
mesh (C1781) and either CPT code 57267 or 49568 (Implantation of mesh 
or other prosthesis for incisional or ventral hernia repair). We 
examined the bills for CPT code 49568 in addition to those for CPT code 
57267 because it was a high volume procedure that also used implantable 
mesh, and we expected that the extra volume would improve our chances 
of identifying meaningful charge data.
    We found 210 claims with charges reported for both CPT code 57267 
and HCPCS code C1781 on the same day and 6,345 claims with reported 
charges for both CPT code 49568 and HCPCS code C1781 on the same day. 
Costs developed from these two claims subsets included the cost of the 
implanted mesh device that was used in performing the procedure. Table 
13 published in the CY 2007 OPPS proposed rule displayed the median 
costs from those claims (71 FR 49562). The costs shown in the column 
titled ``Line-item Median Cost'' of Table 13 were those we obtained by 
looking at all CY 2005 OPPS claims upon which charges for both the 
procedure code (either CPT code 57267 or 49568) and the code for the 
implantable mesh (HCPCS code C1781) were reported. The costs shown in 
the column titled ``Single Claims Median Cost'' were the median costs 
calculated using only single procedure claims for the specific 
procedure that also included the C-code for the mesh.
    Our additional data analysis supported the APC Panel presenter's 
assertion that the cost of the mesh was greater than 50 percent of the 
total cost of CPT code 57267, but it also indicated that the mesh cost 
was far less than 50 percent of the payment amount for APC 0154. In CY 
2006, the payment rate for APC 0154 was $1,704.59, and the payment when 
the multiple procedure discount was taken was $852.30, which was much 
greater than both the line-item median cost of the mesh and the median 
single claims cost of CPT code 57267 (which explicitly included the 
implantable mesh) reflected in our claims data.
    We agreed with the APC Panel that the procedure should be assigned 
to a more clinically appropriate APC, and therefore, we proposed to 
accept its recommendation and reassign CPT code 57267 to APC 0195 
(Level IX Female Reproductive Procedures), with status indicator ``T'' 
for CY 2007. The proposed median cost of APC 0195 was $1,777 for CY 
2007, very comparable to the CY 2006 median cost of APC 0154, where CPT 
code 57267 was assigned for CY 2006. The median cost for the procedure 
remained very low in comparison with other procedures assigned to APC 
0195; therefore, we believe that payment for the service when the 
multiple procedure reduction was applied would be appropriate. While 
not affecting the procedure's payment significantly, this reassignment 
improved the clinical homogeneity of APCs 0154 and 0195.
    Comment: The commenters generally believed that CPT code 57267 
should be assigned to APC 0202 (Level X Female Reproductive 
Procedures), which is a device-dependent APC and for which the proposed 
CY 2007 median cost is $2,534.46. They stated that the analyses that 
CMS performed for the proposed rule to identify costs for the procedure 
described by CPT code 57267 when billed with the HCPCS code C1781 for 
the mesh implant were incorrect because the mesh devices that are used 
in pelvic floor repair are best described by HCPCS codes C1762 
(Connective tissue, human (includes fascia lata)) and C1763 (Connective 
tissue, non-human (includes synthetic)). One commenter provided data 
showing the costs of four procedures, including CPT codes 57240 
(Anterior colporrhaphy, repair of cystocele with or without repair of 
urethrocele) and 57250 (Posterior colporrhaphy, repair of rectocele 
with or without perineorrhaphy), when performed with and without the 
graft insertion procedure, CPT code 57267. Their data indicated that 
the median cost for CPT code 57267, including the device (C1762 or 
C1763), ranged from $946 to $1,465, and that, on average, the cost was 
$1,254.
    Response: In response to the comments, we performed additional 
analyses of claims for CPT code 57267 that included the two types of 
mesh/connective tissues devices coded with HCPCS codes C1762 and C1763, 
as well as those with device code C1781 that we presented in the 
proposed rule. We analyzed all single and ``pseudo'' single claims and 
multiple claims for CPT code 57267 reported with one of the 3 device 
codes (C1762, C1763, and C1781) and examined the line-item cost for 
each of the three devices, based upon our belief that the cost of the 
add-on repair procedure was principally due to the device cost. The 
results of our study showed that the median line-item costs for device 
codes C1762 and C1763 on claims for the pelvic floor repair procedure 
were $810.72 and $503.71, respectively, compared to $352.20 for device 
code C1781.
    Although the commenters stated that the graft insertion procedure 
to repair the pelvic floor was performed using only the connective 
tissue products coded by device codes C1762 and C1763, there is no 
guidance with regard to use of the CPT code 57267 that specifically 
restricts the type of device that may be reported with that code. In 
the list of device category codes and their definitions posted on the 
CMS Web site, we indicate that device code C1781 is defined as, ``A 
mesh implant or synthetic patch composed of absorbable or non-
absorbable material that is used to repair hernias, support weakened or 
attenuated tissue, cover tissue defects, etc.'' We also note in the 
definition that other device codes should be used for reporting 
connective tissue when used to treat urinary incontinence. There are 
far more CY 2005 claims for CPT code 57267 with device code C1781 than 
with either of the device codes presented by the commenters. Therefore, 
the CY 2005 claims data for the procedure are more reflective of the 
use of the mesh reported with device code C1718 than of the mesh the 
commenters believed was most often used. Table 15 displays the numbers 
of claims and the median costs found in our analyses.
    We continue to believe that assignment of CPT code 57267 to APC 
0195 is appropriate and ensures adequate payment for the procedure, 
even when the multiple procedure discount is taken. Based on the 
typical cost of any one of the mesh/connective tissue devices that are 
used in the service, 50 percent of the payment for APC 0195, based on 
its CY 2007 median cost of $1742.20, should be appropriate. Assignment 
to APC 0202, with a median cost of $2,534.46, would result in 
overpayment for the procedures.

[[Page 68049]]



                     Table 15.--Median Costs of HCPCS Codes C1762, C1763 and C1781 and 57267
----------------------------------------------------------------------------------------------------------------
                                                                                      CY 2005     CY 2005  line-
                 HCPCS code                            Short descriptor            frequency of     item median
                                                                                   total claims        cost
----------------------------------------------------------------------------------------------------------------
C1762 (billed with 57267)..................  Conn tiss, human (inc fascia)......              22         $810.72
C1763 (billed with 57267)..................  Conn tissue, non-human.............              55          503.71
C1781 (billed with 49568)..................  Mesh (implantable).................             175          352.20
----------------------------------------------------------------------------------------------------------------

    After carefully considering the public comments received, we are 
finalizing our proposal to reassign CPT code 57267 to APC 0195 without 
modification.
b. Percutaneous Renal Cryoablation (APC 0423)
    During the March 2006 APC Panel meeting, a presenter requested that 
we reassign CPT code 0135T (Ablation renal tumor(s), unilateral, 
percutaneous, cryotherapy) from APC 0163 (Level IV Cystourethroscopy 
and other Genitourinary Procedures) to APC 0423 (Level II Percutaneous 
Abdominal and Biliary Procedures). The presenter provided information 
about the costs of performing these procedures and compared the 
resource requirements for the procedures to those for CPT code 47382 
(Ablation, one or more liver tumor(s), percutaneous, radiofrequency), 
which is currently assigned to APC 0423. The presenter proposed 
reassignment of CPT code 0135T to APC 0423 because that was where CPT 
code 47382 was assigned, and stated that the costs of the two 
procedures were very similar.
    Based on the information presented, the APC Panel recommended that 
we reassign CPT code 0135T from APC 0163 to APC 0423 for CY 2007.
    CPT code 0135T is new for CY 2006 and, therefore, we had no claims 
data upon which to base our APC assignment decision. The procedure 
currently has an interim assignment to APC 0163, with a CY 2006 payment 
amount of $1,999.35.
    In the CY 2007 OPPS proposed rule, we proposed to accept the APC 
Panel's recommendation to reassign CPT code 0135T to APC 0423 for CY 
2007. We believed that assignment of CPT code 0135T to APC 0423 was 
clinically appropriate, and the CY 2007 proposed median cost of APC 
0423 of $2,410.33 was reasonably close to our expectations regarding 
the resource requirements for the renal cryoablation procedure. The APC 
Panel did not discuss this procedure again at its August 2006 meeting, 
nor were there any public presentations on this issue at that meeting.
    Comment: Several commenters approved of the proposed reassignment 
of CPT code 0135T from APC 0163 to APC 0423 for CY 2007 because this 
move placed the percutaneous cryoablation procedure with other similar 
procedures. However, the commenters were concerned that the payment 
rate for CPT code 0135T was inadequate and did not reflect the total 
cost incurred by hospitals in providing this service. The commenters 
also indicated that the payment rate for CPT code 0135T was not based 
on timely data or accurate hospital claims. The commenters believed 
that the proposed payment rate would not cover the costs of the 
expensive cryoablation probes used in performing the procedures. One 
commenter indicated that the average cost of one probe was about 
$1,000, and the average procedure used between 2.3 and 2.5 probes. 
Another commenter submitted copies of invoices showing the costs of the 
probes. The commenter urged CMS to reevaluate the payment for APC 0423, 
because an underpayment could result in hospitals not offering this 
procedure, thereby creating an access barrier for Medicare patients. 
Several commenters requested that CMS use all available data, including 
external data, to determine the appropriate payment rate for APC 0423.
    Response: We reviewed the data for APC 0423, considered the 
comments, and examined all available information regarding the 
procedure described by CPT code 0135T, as well as other procedures that 
are separately payable under the OPPS and for which we have claims 
data. In addition, we reviewed the recommendation of the APC Panel from 
its March 2006 meeting that was based upon the request of a presenter. 
Based on our evaluation, we believe that we have appropriately assigned 
CPT code 0135T to APC 0423 for CY 2007 based on clinical and resource 
homogeneity considerations. Under the standard OPPS methodology, the 
APC payment rate is established based on CY 2005 claims data for those 
services for which there are data. One service also assigned to APC 
0423 has significant claims volume, and its median costs have been 
stable over the past several years. The final median cost of APC 0423 
upon which the payment rate for CPT code 0135T is based is $2,283.08. 
We believe that this payment will be sufficient to ensure access to 
this service for Medicare beneficiaries.
    Comment: Several commenters acknowledged that cryoablation and 
radiofrequency percutaneous ablation procedures for renal tumors were 
clinically similar; however, there were major resource differences in 
the required equipment and the technology-specific probes. One 
commenter indicated that the radiofrequency ablation procedure involves 
the use of only one probe, while the cryoablation procedure requires, 
on average, 2.5 probes.
    Response: We believe that CPT code 0135T is appropriately assigned 
to APC 0423 because it is placed with other procedures that share 
clinical and resource homogeneity. If hospitals use more than one probe 
in performing the renal cryoablation procedure, we expect hospitals to 
report this information on the claim and adjust their charges 
accordingly. Hospitals should report the number of cyroablation probes 
used to perform CPT code 0135T as the units of HCPCS code C2618 (Probe, 
cryoablation), which describes these devices, with their charges for 
the probes. Since CY 2005, we have required hospitals to report device 
HCPCS codes for all devices used in procedures if there are appropriate 
HCPCS codes available. In this way, we can be confident that hospitals 
have included charges on their claims for costly devices used in 
procedures when they submit claims for those procedures.
    Comment: Several commenters indicated that in the CY 2007 OPPS 
proposed rule we acknowledged the lack of claims data to set the 
payment rate for the renal cryoablation procedure reported with CPT 
code 0135T. They believed that CMS should assign CPT code 0135T to a 
New Technology APC and base its payment on the actual cost of 
performing the procedure. One commenter reported that the renal 
cryoablation procedure was a relatively new procedure that had only 
rarely been performed in the outpatient setting. The commenter also 
noted that assigning CPT code 0135T to a New Technology

[[Page 68050]]

APC would allow CMS time to obtain meaningful outpatient cost 
information for the procedure, so that CMS could eventually place the 
procedure in an appropriate clinical APC. The commenter added that 
prior to January 1, 2006, there was no specific HCPCS code that 
accurately described the renal cryoablation procedure, and, as a 
result, the service was reported by those hospitals performing the 
procedure under the general unlisted CPT code 53899. Because of the use 
of the unlisted CPT code, the commenter indicated that it would be 
impossible to identify the historical hospital outpatient claims that 
were related to percutaneous renal cryotherapy.
    Response: While we previously acknowledged the lack of claims data 
in setting the payment rate for CPT code 0135T, we have commonly 
assigned a new service or procedure without claims data to a clinical 
APC that we believed appropriately reflected the cost and clinical 
features of the procedure. We often have relevant information available 
to us based on claims data for other services historically paid under 
the OPPS, as well as data provided to us by the public. In the case of 
CPT code 0135T specifically, the APC Panel at its March 2006 meeting 
recommended that we reassign this code from APC 0163 to APC 0423 for CY 
2007. Based on this recommendation and our comprehensive review of the 
procedures assigned to APC 0423, we believe that we have assigned the 
renal cryoablation procedure to an appropriate clinical APC, 
specifically APC 0423, which reflects clinical homogeneity and 
comparable resource costs among the procedures assigned to the APC for 
CY 2007. We note that we expect to have claims data for CPT code 0135T 
available for the CY 2008 OPPS update.
    After carefully considering all the public comments received, we 
are reassigning CPT code 0135T to APC 0423, as proposed, without 
modification. The final APC 0423 median cost is $2,283.08.
c. Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance 
Guidance (MRgFUS) (APCs 0195 and 0202)
    We received many public comments concerning the APC assignments for 
HCPCS codes 0071T and 0072T.
    In the CY 2006 final rule we assigned magnetic resonance guided 
focused ultrasound ablation of uterine fibroids (MRgFUS) procedures, 
CPT codes 0071T and 0072T, to APCs 0195 (Level IX Female Reproductive 
Procedures) and 0202 (Level X Female Reproductive Procedures), 
respectively, for CY 2006. We made those reassignments in response to 
public comments to our proposed rule of July 25, 2005, in which we had 
proposed to assign the procedures to APC 0193 (Level V Female 
Reproductive Procedures) for CY 2006. These services had been assigned 
to APC 0193 since their implementation in the OPPS in CY 2005. We 
proposed no changes to their final CY 2006 assignments for CY 2007.
    Comment: Although our assignments of the procedures were to 
separate, higher paying APCs for CY 2006 than their assignments for CY 
2005, commenters on the CY 2007 proposed rule believed that the 
procedures' assignments still resulted in significant underpayment. The 
commenters asserted that while MRgFUS treats anatomical sites that are 
similar to other procedures assigned to APCs 0195 and 0202, the 
resources utilized differ dramatically. Further, they stated that 
treatment of uterine fibroids using the MRgFUS procedure is more cost 
effective for the Medicare program and for beneficiaries because the 
recovery time is shorter, and beneficiaries would be spared the need 
for hysterectomies.
    The commenters indicated that the most appropriate assignment for 
the MRgFUS procedures would be APC 0127 (Level IV Stereotactic 
Radiosurgery) based on their analyses of the procedures' resource use 
and clinical characteristics. The similarities between the two 
technologies that were presented by the commenters included their 
clinical indication to treat non-invasive tumors by using focused 
ionizing radiation (stereotactic radiosurgery) or acoustic waves 
(MRgFUS) to destroy the tumor tissue.
    Further, the commenters argued that the procedures require similar 
hospital resources: planning prior to treatment; specialized equipment 
housed in treatment rooms; continuous monitoring during treatment; and 
120 to 300 minutes to perform the treatment.
    One commenter sent data that compared the hospital charges for 
three MRgFUS cases to those for five stereotactic radiosurgery (SRS) 
procedures. Those data showed charges for CPT code 0071T of $18,215 and 
for 0072T, $22,122 and $23,463, and for SRS, charges ranging from 
$21,360 to $28,790. In addition, many of the commenters reported that 
their hospitals charge between $18,000 and $24,000 for each MRgFUS 
treatment.
    Response: As we stated in the November 10, 2005 final rule, we 
believe that MRgFUS treatment bears a significant relationship to 
technologies already in widespread use in hospitals, in particular 
magnetic resonance imaging (MRI) and ultrasound services. The use of 
focused ultrasound for thermal tissue ablation has been in development 
for decades, and the recent application of MRI to focused ultrasound 
therapy provides monitoring capabilities that may make the therapy more 
clinically useful. We believe that MRgFUS therapy is a new and 
integrated application of existing technologies (MRI and ultrasound) 
and that the technology used in this service fits as well into existing 
clinical APCs for female reproductive services, as do many other 
modalities that are currently assigned to those clinical groups. 
Retaining them in clinical APCs with other female reproductive 
procedures will enable us both to set accurate payment amounts and to 
maintain appropriate clinical homogeneity of the APCs.
    The similarity of the charges for MRgFUS and SRS as reflected in 
the examples provided by one commenter does not convince us that the 
level of hospital resources used to provide MRgFUS is the same as for 
SRS. APC assignments are made based on consideration of both hospital 
resources and clinical homogeneity. There are many OPPS claims with 
similar charges, but where the reported procedures have nothing in 
common with one another clinically. We do not assign those procedures 
to the same clinical APC.
    In our CY 2005 claims data, there are two claims for CPT code 0071T 
but none for CPT code 0072T and 3,346 claims for the single SRS service 
assigned to APC 0127. Those data show the median cost for SRS is $8,461 
and the median cost for the two MRgFUS claims is $1,026. We realize the 
limited nature of the data from which to draw any conclusions about 
cost, but because treatment of uterine fibroids is most common among 
women younger than 65 years of age, we do not expect that there ever 
will be many Medicare claims for those procedures. Nevertheless, we do 
not see a compelling reason to except MRgFUS from our established 
policy to rely on our claims as the basis for weight-setting under the 
OPPS.
    Further, and in contrast with SRS, the MRI equipment used to 
provide the MRgFUS therapy can also be used to perform conventional MRI 
procedures and does not necessarily represent an additional capital 
expense for the hospital. Those costs should be allocated accordingly 
so that amortization will be shared by those other tests. In addition, 
we remind commenters that the OPPS was originally set up to be budget 
neutral to the prior system, which under several provisions of the 
statute, paid

[[Page 68051]]

approximately 82 percent of reported hospital outpatient department 
costs as shown on the cost reports. Therefore, payment rates for 
individual services are set, in effect, to reflect relative resource 
use within a payment system that pays, on average, at what was a 
discount of approximately 18 percent. Because the OPPS is a prospective 
payment system as well, payment may be more or less than a provider's 
costs in any specific case. We expect that our payment rates generally 
will reflect the costs that are associated with providing care to 
Medicare beneficiaries in cost-efficient settings.
    Prior to assigning CPT codes 0071T and 0072T to APCs 0195 and 0202 
respectively, we compared the necessary hospital resources for the 
MRgFUS procedures, including specialized equipment, MRI/procedure room 
time, personnel, anesthesia and other required resources, to various 
other procedures for which we have historical hospital claims data. In 
addition, we took into consideration projected costs for the MRgFUS 
procedures submitted to us, and other available information regarding 
the clinical characteristics and costs of those services. We do not 
believe that there are significant clinical similarities between MRgFUS 
and the multi-source photon SRS procedure assigned to APC 0127. This 
SRS procedure is generally performed on intracranial lesions, and 
requires immobilization of the patient's head in a frame that is 
screwed into the skull. Several hundred converging beams of gamma 
radiation are applied to the target lesion, requiring their accurate 
placement to the fraction of a millimeter. In contrast, during MRgFUS, 
MRI guidance is utilized to confirm tissue heating, while multiple 
sonications at various points in the fibroid treatment area are 
executed until the entire target volume has been treated. Therefore, we 
do not think these two types of procedures are clinically similar, nor 
do we believe they require comparable hospital resources based on the 
considerations described previously that went into our CY 2006 APC 
assignments for MRgFUS and SRS procedures.
    We continue to believe that the assignments of CPT codes 071T and 
072T for MRgFUS procedures to APCs 0195 and 0202 respectively for CY 
2007 will make appropriate OPPS payments for MRgFUS services, thereby 
ensuring access for Medicare beneficiaries who need them.
    After careful consideration of the public comments received, we are 
finalizing our proposed CY 2007 APC assignments of CPT codes 071T and 
072T, without modification.
d. Laser Vaporization of Prostate (APC 0429)
    For CY 2007, we proposed to assign CPT code 52648 (Laser 
vaporization of prostate, including control of postoperative bleeding, 
complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration 
and/or dilation, internal urethrotomy and transurethral resection of 
prostate are included if performed)) to APC 0429 (Level V 
Cystourethroscopy and other Genitourinary Procedures), with a proposed 
median cost of $2,651.79. The procedure was assigned to APC 0429 for CY 
2006.
    Comment: One commenter indicated that the proposed assignment of 
CPT code 52648 to APC 0429 seemed appropriate but asked CMS to use only 
claims for CPT code 52648 that also contained HCPCS code C9713 
(Noncontact laser vaporization of prostate, including coagulation 
control of intraoperative and postoperative bleeding) to calculate the 
median cost for APC 0429. The commenter believed that by using single 
bills that did not also contain HCPCS code C9713, CMS may have excluded 
the correctly coded claims.
    Response: We agree that assignment of CPT code 52648 to APC 0429 is 
appropriate, but we disagree that we should require HCPCS code C9713 to 
be on all claims for CPT code 52648 as either a condition of payment 
for CPT code 52648 or to calculate the median cost of APC 0429. HCPCS 
code C9713 was created to describe the service for laser vaporization 
of the prostate because we did not believe that CPT code 52648, as 
defined before January 1, 2006, described the same service, and HCPCS 
code C9713 should not have been included on any claims with CPT code 
52648. HCPCS code C9713 was deleted effective December 31, 2005, as a 
result of the change to the descriptor of CPT code 52648. Hospitals 
that billed both codes on the same claim in CY 2005 were billing 
incorrectly, as HCPCS code C9713 did not describe the device used to 
furnish the service.
    After carefully considering the public comment received, we are 
finalizing our CY 2007 proposal to assign CPT code 52648 to APC 0429 
for CY 2007. The CY 2007 final median cost of APC 0429 is $2,633.85.
e. Gastrointestinal Procedures with Stents (APC 0384)
    For CY 2007, we proposed to calculate the median cost of APC 0384 
(GI Procedures with Stents) using only claims that pass the device 
edits and which do not contain token charges for the device HCPCS codes 
on the claims. The proposed rule median cost of APC 0384 was $1,400.71.
    Comment: The commenters asked that CMS calculate the median by 
applying the same device edits for CPT codes 43268 (Endoscopic 
retrograde cholangiopancreatography (ECRP); with retrograde insertion 
of tube or stent into bile or pancreatic duct); 43269 (Endoscopic 
retrograde cholangiopancreatography (ECRP); with retrograde removal of 
foreign body and/or change of tube or stent); and 43219 (Esophagoscopy, 
rigid or flexible; with insertion of plastic tube or stent) that were 
applied to calculate the CY 2006 OPPS median cost. The commenters 
stated that CMS used only claims containing stent device codes to 
calculate the median cost for APC 0384 for CY 2006 OPPS. They believed 
that the CY 2007 OPPS median cost for APC 0384 would be significantly 
higher if only claims that contained the stent device codes were used 
in the calculation.
    Response: We have not calculated the CY 2007 median cost for APC 
0384 using only claims that contain the HCPCS codes for stents for the 
procedures reported under CPT codes 43268 and 43219, because the 
procedures may be performed with tubes rather than stents. There are no 
device HCPCS codes for the tubes that may be used. Similarly, the 
procedure identified by CPT code 43269 may or may not use either a 
stent or a tube, and, therefore, it would be erroneous to require that 
a stent be reported on the claim. We assume that where a stent HCPCS 
code is not reported on the claim, the charge for the procedure 
incorporates the charge for the tube if one was used in the case of CPT 
codes 43268 and 43219, or in the case of CPT code 43269, we assume that 
no stent or tube was used at all. It is also possible that if the 
hospital inserted a tube, the hospital provided a charge for the tube 
under a revenue code with no HCPCS code. The other CPT codes in the APC 
require the use of a stent (and make no provision for substitution of a 
tube) and, therefore, we require that a stent HCPCS C-code be reported 
on the claims for those services. This is the same methodology and the 
same set of device edits for these procedures that were applied to 
calculate the median cost of APC 0384 to establish its CY 2006 OPPS 
payment rate. Our discussion of our final policy for setting the 
payment rates for device-dependent APCs, including APC 0384, is 
included in section IV.A.2. of this final rule with comment period.

[[Page 68052]]

See the OPPS device edits at http://www.cms.hhs.gov/HospitalOutpatientPPS/ under ``downloads'' for the device edits in 
place for this APC for each calendar quarter since October 2005.
    After carefully considering the public comments received, we are 
finalizing our CY 2007 proposal for APC 0384 without modification. The 
final median cost for APC 0384 is $1,402.31.
f. Endoscopy With Thermal Energy to Sphincter (APC 0422)
    CPT code 43257 (Upper gastrointestinal endoscopy, including 
esophagus, stomach, and either the duodenum and/or jejunum as 
appropriate; with delivery of thermal energy to the muscle of lower 
esophageal sphincter and/or gastric cardia, for treatment of 
gastroesophageal reflux disease), effective January 1, 2005, is used 
for esophagoscopy with delivery of thermal energy to the muscle of the 
lower esophageal sphincter and/or gastric cardia for the treatment of 
gastresophageal reflux disease. This code describes the Stretta 
procedure, including use of the Stretta System and all endoscopies 
associated with the Stretta procedure. Prior to CY 2005, the Stretta 
procedure was recognized under HCPCS code C9701 from January 1, 2004, 
through December 31, 2004, in the OPPS. For the CY 2005 OPPS, HCPCS 
code C9701 was deleted and CPT code 43257 was utilized for the Stretta 
procedure. In CY 2005, the Stretta procedure was transitioned from a 
New Technology APC to clinical APC 0422 (Level II Upper GI Procedures) 
based on several years of hospital cost data. Procedures within APC 
0422 were similar to the Stretta procedure in terms of clinical 
characteristics and resource use. For both CYs 2005 and 2006, we 
specifically calculated the median cost for the Stretta procedure 
reported with CPT code 43257 taking into account the codes that 
hospitals billed for the service in CYs 2003 and 2004, which included 
HCPCS code C9701 and one unit of endoscopy service. For CY 2007, we 
proposed to continue with the current APC assignment for the Stretta 
procedure, with no need for a special median cost calculation.
    We received several public comments in response to the CY 2007 
proposed payment rate for the Stretta procedure, in particular with a 
focus on the median cost methodology.
    Comment: Some commenters objected to the APC assignment of the 
Stretta procedure to APC 0422 and cited the use of the CY 2004 claims 
data in determining its median cost for CY 2007. The commenters 
indicated that CMS should recalculate the median cost for CPT code 
43257 to ensure that all claims contributing to the median reflect the 
resources of the endoscopic procedures that are part of this procedure.
    Response: The commenters cited the CY 2004 claims as part of their 
objection. However, we used claims data from CY 2005 for all services, 
including CPT code 43257, in determining the payment rates for CY 2007. 
As we stated in the CY 2007 OPPS proposed rule, median costs for the CY 
2007 OPPS update were based on the CY 2005 hospital claims data. APC 
assignments are based on clinical homogeneity and comparable resource 
utilization for all CPT and HCPCS codes within an APC. In the case of 
APC 0422, we believe that the procedures assigned to this APC are 
similar in costs and resource consumption, with median costs for the 
significant procedures assigned to the APC of $1,475 to $2,084, well 
within the 2 times rule limits.
    Comment: Several commenters requested that CMS create a new APC 
that includes both CPT codes 43257 and 0008T (Upper gastrointestinal 
endoscopy, including esophagus, stomach, and either the duodenum and/or 
jejunum as appropriate, with suturing of the esophagogastric junction) 
to appropriately cover the costs associated with performing these 
procedures. One commenter requested that CMS create a new APC to which 
CMS would assign CPT codes 43257 and 0008T, and that CMS use a 
different methodology to calculate the median cost. The commenter 
indicated that because CPT codes 43228 and 43830 have higher volumes 
but lower costs, the inclusion of them in the same APC as CPT code 
43257 does not lead to payment of CPT code 43257 at a level that is 
appropriate to pay the costs of the service. The same commenter 
indicated that the continued inclusion of CPT codes 43228 and 43830 
decrease the payment rate for many of the procedures placed in APC 
0422. The commenter believed that creating the new APC was analogous to 
what CMS proposed to do for vascular access devices in the proposed 
rule.
    Response: We disagree with the commenters. We believe that the 
procedures in APC 0422 contain similar procedures for the treatment of 
gastroesophageal reflux disease, and these services are, therefore, 
appropriately assigned based on clinical homogeneity and resource use. 
Thus, for CY 2007, CPT code 43257 will remain in APC 0422. CPT code 
0008T will be deleted as of January 1, 2007. For the CY 2007 OPPS, the 
payment for APC 0422 is based on the final median cost of $1,573.89. 
Furthermore, with regard to the commenter's analogy to a new APC for 
vascular access devices, such a comparison was misplaced as we did not 
propose to create a new APC for vascular access devices in the CY 2007 
OPPS proposed rule.
    Comment: One commenter requested that CMS recompute the median cost 
for CPT code 43257, and suggested two specific options for determining 
a revised median cost. One option suggested by the commenter was that 
CMS add the median cost for CPT code 43235 to the cost of all claims 
for HCPCS code C9701 (CPT code 43257 in CY 2005) that did not also 
contain at least one unit of an endoscopy code on the claim. The 
commenter indicated that these inflated claims costs would then be 
combined with all claims for HCPCS code C9701 that also contain at 
least one unit of an endoscopy code and with the claims for CPT code 
0008T to set the median cost for the APC they wanted CMS to create. The 
commenter suggested that another option would be to use only claims 
that contained both HCPCS code C9701 and CPT codes 43234, 42235, or any 
other endoscopy code to calculate the median cost, which the commenter 
admitted would not yield as robust a set of claims for setting medians.
    Response: We no longer have a need for special calculations to 
develop the median cost of CPT code 43257 because the code itself was 
reported by hospitals in CY 2005 and includes all endoscopies. In 
addition, HCPCS code C9701 was deleted for CY 2005 so we have no claims 
for the service from that year. Further, as we indicated in the CY 2006 
OPPS final rule with comment period that addressed this same issue and 
similar comment (70 FR 68606), we see no reason to create a new APC for 
CPT codes 43257 and 0008T. We believe that the procedures in APC 0422 
contain similar procedures for the treatment of gastroesophageal reflux 
disease, and therefore, the APC is appropriately structured based on 
clinical homogeneity and resource use.
    After carefully considering the public comments received, we are 
finalizing our proposal for assignment of CPT code 43257 to APC 0422 
for CY 2007, with a median cost of $1,573.89.
5. Ocular Procedures
a. Keratoprosthesis (APC 0293)
    CPT code 65770 (Keratoprosthesis) is a surgical procedure for 
implantation of a keratoprosthesis, an artificial cornea. In the CY 
2007 proposed rule, we indicated that we believed that the 
keratoprosthesis device that is required

[[Page 68053]]

for the implantation is described by HCPCS code C1818 (Integrated 
keratoprosthesis), a device category that received transitional pass-
through payment under the OPPS from July 2003 through December 2005. 
When the pass-through status for the device expired for CY 2006 and the 
costs of the device were packaged into the implantation procedure, CPT 
code 65770 continued to be assigned to APC 0244 (Corneal Transplant), 
with a payment rate of about $2,275, despite an increase in the median 
cost of the implantation procedure of about $1,200 associated with the 
packaging of the device. There is no 2 times violation in APC 0244 for 
CY 2006.
    At the March 2006 meeting of the APC Panel, following a 
presentation regarding the procedure to implant a keratoprosthesis that 
described the clinical and hospital resource characteristics of CPT 
code 65770, the Panel recommended moving CPT code 65770 to a more 
appropriate APC in order to make appropriate payment. We agreed with 
the recommendation of the APC Panel. At the time of the proposed rule, 
claims data from CY 2005 demonstrated that the median cost for 
implantation of a keratoprosthesis of $3,127.51 remained significantly 
higher than the median costs of other procedures assigned to APC 0244, 
although there was no 2 times violation. In addition, CPT code 65770 
contributed less than 1 percent of the single claims in the APC 
available for ratesetting, and it was likely to continue to be an 
uncommon procedure among Medicare beneficiaries, resulting in its 
persistent small contribution to the median cost of APC 0244. 
Therefore, for CY 2007, we proposed to create a new APC 0293 (Level V 
Anterior Segment Eye Procedures) with a median cost of $3,127.51 and to 
move CPT code 65770 into that APC in order to more appropriately pay 
for the procedure and the related device. CPT code 65770 was the only 
code proposed for assignment to that APC.
    Comment: One commenter and a presenter to the APC Panel during its 
August 2006 meeting requested that the procedure be paid at a higher 
rate than the proposed payment rate. They believed that our cost data 
were inaccurate and understated the cost of the implantable device, 
HCPCS code C1818. The commenters reported that the device, a 
biointegratable artificial cornea, costs approximately $7,000, far more 
than the proposed $3,116.62 OPPS payment rate for the procedure to 
implant the device.
    At its August 2006 meeting, the APC Panel recommended that CMS 
consider external data for these procedures to validate whether the 
claims used for ratesetting were properly coded and make appropriate 
adjustments to the OPPS payment rate if necessary. Further, the Panel 
recommended that CMS implement a device edit that would ensure that the 
device code (HCPCS code C1818) is included on claims for the 
keratoprosthesis procedure.
    The commenters provided hospital data that showed that many 
hospitals that performed the procedure which may be reported for 
implantation of the costly biointegratable artificial cornea described 
by HCPCS code C1818 did not report charges for the device on their 
bills to Medicare. Further, one commenter performed analyses of 
Medicare hospital outpatient claims data and found that if CMS used 
only single procedure claims that included HCPCS code C1818 and CPT 
code 65770 to establish the median cost for APC 0293, it would be more 
than $10,000 and would result in a payment rate that would be adequate 
to cover the costs of implantation of the integrated keratoprosthesis 
device.
    Response: In response to the comments and the APC Panel's 
recommendations, we performed additional analyses of our claims data. 
We noted that a new alphanumeric HCPCS code L8609 (Artificial cornea) 
was established in CY 2006, but there would not have been any claims 
reported for this code in the CY 2005 claims data used for this CY 2007 
OPPS update. We found that only 8 of the 47 single claims for CPT code 
65770 included the HCPCS device code C1818. The median cost for those 
few claims was $10,715.30, consistent with the commenter's data 
analyses.
    Upon further exploration of the background of HCPCS device code 
C1818, we noted that we had provided specific guidance concerning the 
device code in the June 2003 Transmittal A-03-051, explaining, ``The 
device is composed of a flexible, one-piece biocompatible polymer * * 
*.'' We are aware of at least one other device that may be inserted 
during the procedure described by CPT code 65770, and that 
keratoprosthesis is a two-part device that would not be appropriately 
described by HCPCS code C1818. We have been told that the device is 
significantly less costly than the device described by HCPCS code 
C1818, the one-piece biointegratable keratoprosthesis. Because there 
are at least two devices with different costs that could have been used 
in CY 2005 to perform CPT code 65770, but there was no HCPCS code in CY 
2005 for the two-part keratoprosthesis not described by HCPCS code 
C1818, it would not be appropriate for us to use only claims reporting 
HCPCS code C1818 to calculate the median cost for CPT code 65770. If we 
were to follow the recommendation of the commenter, we could be 
systematically and incorrectly excluding claims for CPT code 65770 that 
may have been correctly coded at the time by hospitals implanting a 
two-part keratoprosthesis with a lower device cost than the cost of the 
one-piece device coded by CPCS code C1818.
    The OPPS is a prospective payment system that pays based on the 
median cost of procedures assigned to APC groups, and to the extent 
that various devices with dissimilar costs may be used to provide the 
same procedure, those different device costs are packaged into the 
procedural payment in relationship to their utilization in the 
procedure. Therefore, we do not believe the 47 single claims from CY 
2005 used for ratesetting for APC 0293 were miscoded, and we do not 
believe adjustments to the payment rate for APC 0293 established based 
on the standard OPPS methodology are needed for CY 2007.
    Where there are device HCPCS codes for all possible devices that 
could be used to perform a procedure that always requires a device and 
the APC is designated a device-dependent APC, we have commonly 
instituted device edits that prevent payment of claims that do not 
include both the procedure and an acceptable device code. In that way, 
hospitals become aware of the proper coding requirements, and we can be 
confident that our procedure claims include charges for the necessary 
devices so we can establish appropriate payment rates for those 
procedures.
    Because there was a new, more general HCPCS L-code (L8609) created 
for the artificial cornea in CY 2006 that may be used to report all 
keratoprostheses not already described by HCPCS code C1818, we are 
accepting the APC Panel's recommendation regarding the establishment of 
device edits for CPT code 65770. We will establish a device edit in CY 
2007 for CPT code 65770 that requires reporting of an appropriate 
device HCPCS code to ensure that all claims for CPT code 65770 in CY 
2007 and future years include charges for a required device. However, 
to the extent that devices with different costs are used to provide the 
keratoprosthesis procedure, unless the CPT code descriptor for the 
service is revised or more specific CPT codes are developed, our claims 
data will continue to reflect highly variable costs

[[Page 68054]]

for the services that are provided using the full spectrum of 
keratoprosthesis devices.
    After carefully considering the comments received, we are adopting 
our proposal without modification to assign CPT code 65770 to APC 0293, 
with a median cost of $3,177.05 for CY 2007. We are also assigning a 
procedure-to-device edit for CPT code 65770 with APC 0293.
b. Eye Procedures (APCs 0232, 0235, and 0241)
    In Addendum B of the CY 2007 proposed rule (71 FR 49702), we 
proposed to assign a payment rate of $368.07 for APC 0232 (Level I 
Anterior Segment Eye Procedures), a payment rate of $250.82 for APC 
0235 (Level I Posterior Segment Eye Procedures), and a payment rate of 
$1,529.55 for APC 0241 (Level IV Repair and Plastic Eye Procedures).
    Comment: Several commenters questioned the reasoning behind the 
payment reductions for APCs 0232, 0235, and 0241 when their facilities 
experienced increased costs for the procedures assigned to these APCs. 
Specifically, the commenters questioned why the payment rate for APC 
0232 declined from $411.84 for CY 2006 to the proposed payment rate of 
$368.07 for CY 2007; why the payment rate for APC 0235 declined from 
$285.21 for CY 2006 to the proposed payment rate of $250.82 for CY 
2007; and why the payment rate for APC 0241 declined from $1,806.03 for 
CY 2006 to the proposed payment rate of $1,529.55 for CY 2007. At the 
same time, several commenters supported the proposed payment increases 
for APCs 0242 (Level V Repair and Plastic Eye Procedures), 0245 (Level 
I Cataract Procedures without IOL Insert), 0247 (Laser Eye Procedures 
Except Retinal), 0248 (Laser Retinal Procedures), 0673 (Level IV 
Anterior Segment Eye Procedures), and 0699 (Level IV Eye Tests and 
Treatment). The commenters requested that CMS reexamine the proposed 
payments for APCs 0232, 0235, and 0241.
    Response: Each year, we reevaluate APC assignments for procedures, 
services, and items paid under the hospital OPPS based on claims data 
paid by Medicare to set annual payment rates. Based on our analyses, we 
make changes to the APC assignments when necessary. As we stated in the 
CY 2007 OPPS proposed rule (71 FR 49514), we used approximately 50.7 
million whole claims that reflected services furnished on or after 
January 1, 2005, and before January 1, 2006, to recalibrate the APC 
relative payment weights for CY 2007. While the payment rates for many 
APCs remain stable over time, in the absence of APC reconfiguration, it 
is not unusual for the payment rates for certain APCs to vary modestly 
from year to year, similar to the approximately 10-percent decrease in 
median costs observed for APCs 0232 and 0235 for CY 2007. However, as 
the commenters noted, other eye procedure APCs also had proposed 
increases for CY 2007. The CY 2007 median costs for APCs 0232 and 0235 
have been calculated based upon CY 2005 claims using the standard OPPS 
methodology. In the case of APC 0241, the commenter is mistaken to 
believe that the CY 2006 OPPS payment rate for the APC was $1,806.03. 
The CY 2006 OPPS payment rate for APC 0241 was $1,378.76. Therefore, 
the proposed payment rate of $1,529.55 for APC 0241 was a proposed 
payment rate increase for CY 2007.
    After carefully considering the public comments received, we are 
finalizing our CY 2007 proposal for APCs 0232, 0235, and 0241 without 
modification, with final median costs of $370.77, $240.36, and 
$1,543.32, respectively.
c. Amniotic Membrane for Ocular Surface Reconstruction
    In Addendum B of the CY 2007 proposed rule (71 FR 49845), we 
proposed to assign HCPCS code V2790 (Amniotic membrane for surgical 
reconstruction, per procedure) to status indicator ``N'' (packaged).
    Comment: Several commenters requested that CMS consider assigning 
status indicator ``F'' (paid at reasonable cost) to HCPCS code V2790 
rather than status indicator ``N''. One commenter indicated a 
discrepancy in payment policy and status indicator assignment for two 
types of tissues currently used for ocular surface transplants; that 
is, HCPCS code V2785 (Processing, preserving and transporting corneal 
tissue), which is assigned to status indicator ``F'' and HCPCS code 
V2790, which is assigned to status indicator ``N,'' are not treated 
similarly with regard to status indicator assignments and OPPS payment 
policy. The commenters added that payment for items and services 
assigned to status indicator ``N'' is packaged into payment for the 
associated procedures, while payment for items and services assigned to 
status indicator ``F'' is made at reasonable cost, not under the OPPS.
    The commenters believed this discrepancy could create a competitive 
disadvantage and financial disincentive for hospitals to promote the 
treatment of ocular surface diseases using amniotic membrane tissue, 
and ultimately impede beneficiary access to this unique ocular 
reconstructive procedure. The commenters requested that CMS reassign 
HCPCS code V2790 from status indicator ``N'' to status indicator ``F'' 
for CY 2007.
    Response: We appreciate the commenters'' interest in payment for 
tissues used in ocular treatments. The OPPS has provided separate 
payment for corneal tissue acquisition at reasonable cost since the 
beginning of the OPPS, due to the highly variable corneal tissue 
processing fees required for eye banks to provide safe corneal tissue 
from donors as needed for transplant, through special distribution 
channels. These costs may vary substantially and unpredictably, 
depending on philanthropic and in-kind service contributions to eye 
banks that vary from community to community and from year to year. Our 
understanding is that amniotic membrane retrieved from donated 
placental tissues is a processed, cryopreserved, and commercially 
marketed product used for ocular reconstruction that may be stocked and 
stored by hospitals. Therefore, there is no need for HCPCS code V2790 
to be paid based on reasonable cost outside of the OPPS. Instead, like 
many items under the OPPS used in surgical procedures, its prospective 
payment is appropriately packaged into payment for the procedures in 
which it is used.
    After consideration of the public comments received, we are 
finalizing our proposed CY 2007 payment policies without modification 
for HCPCS codes V2785 and V2790 as reflected in their assigned status 
indicators.
6. Other Procedures
a. Skin Replacement Surgery and Skin Substitutes (APC 0025)
    For CY 2006, the AMA made comprehensive changes, including code 
additions, deletions, and revisions, accompanied by new and revised 
introductory language, parenthetical notes, subheadings and cross-
references, to the Integumentary, Repair (Closure) subsection of 
surgery in the CPT book to facilitate more accurate reporting of skin 
grafts, skin replacements, skin substitutes, and local wound care. In 
particular, the section of the CPT book previously titled ``Free Skin 
Grafts'' and containing codes for skin replacement and skin substitute 
procedures was renamed, reorganized, and expanded. New and existing CPT 
codes related to skin replacement surgery and skin substitutes were 
organized into five subsections: Surgical Preparation, Autograft/Tissue 
Cultured Autograft, Acellular Dermal Replacement,

[[Page 68055]]

Allograft/Tissue Cultured Allogeneic Skin Substitute, and Xenograft.
    As part of the CY 2006 CPT code update in the newly named ``Skin 
Replacement Surgery and Skin Substitutes'' section, certain codes were 
deleted that previously described skin allograft and tissue cultured 
and acellular skin substitute procedures, including CPT code 15342 
(Application of bilaminate skin substitute/ neodermis; 25 sq cm), CPT 
code 15343 (Application of bilaminate skin substitute/neodermis; each 
additional 25 sq cm), CPT code 15350 (Application of allograft, skin; 
100 sq cm or less), and CPT code15351 (Application of allograft, skin; 
each additional 100 sq cm). Thirty-seven new CPT codes were created in 
the ``Skin Replacement Surgery and Skin Substitutes'' section, and 
these codes received interim final status indicators and APC 
assignments in the CY 2006 final rule with comment period and were 
subject to comment. At its March 2006 meeting, the APC Panel heard 
several presentations on some of the new CY 2006 CPT codes for skin 
replacement and skin substitute procedures, and CMS has received 
additional information from the public regarding a number of these 
services. In particular, 18 new CPT codes that were created to more 
specifically describe skin allograft, skin replacement, and skin 
substitute procedures were the subject of the APC Panel discussion and 
recommendations. These codes are as follows:
     CPT code 15170 (Acellular dermal replacement, trunk, arms, 
legs; first 100 sq cm or less, or one percent of body area of infants 
and children)
     CPT code 15171 (Acellular dermal replacement, trunk, arms, 
legs; each additional 100 sq cm, or each additional one percent of body 
area of infants and children, or part thereof)
     CPT code 15175 (Acellular dermal replacement, face, scalp, 
eyelids, mouth neck, ears, orbits, genitalia, hands, feet and/or 
multiple digits; first 100 sq cm or less, or one percent of body area 
of infants and children)
     CPT code 15176 (Acellular dermal replacement, face, scalp, 
eyelids, mouth neck, ears, orbits, genitalia, hands, feet and/or 
multiple digits; each additional 100 sq cm, or each additional one 
percent of body area of infants and children, or part thereof)
     CPT code 15300 (Allograft skin for temporary wound 
closure, trunk, arms, legs; first 100 sq cm or less, or one percent of 
body area of infants and children)
     CPT code 15301 (Allograft skin for temporary wound 
closure; trunk, arms, legs; each additional 100 sq cm, or each 
additional one percent of body area of infants and children, or part 
thereof)
     CPT code 15320 (Allograft skin for temporary wound 
closure, face, scalp, eyelids, mouth neck, ears, orbits, genitalia, 
hands, feet and/or multiple digits; first 100 sq cm or less, or one 
percent of body area of infants and children)
     CPT code 15321 (Allograft skin for temporary wound 
closure, face, scalp, eyelids, mouth neck, ears, orbits, genitalia, 
hands, feet and/or multiple digits; each additional 100 sq cm, or each 
additional one percent of body area of infants and children, or part 
thereof)
     CPT code 15340 (Tissue cultured allogeneic skin 
substitute; first 25 sq cm or less)
     CPT code 15341 (Tissue cultured allogeneic skin 
substitute; each additional 25 sq cm)
     CPT code 15360 (Tissue cultured allogeneic dermal 
substitute; trunk, arms, legs; first 100 sq cm or less, or one percent 
of body area of infants and children)
     CPT code 15361 (Tissue cultured allogeneic dermal 
substitute; trunk, arms, legs; each additional 100 sq cm, or each 
additional one percent of body area of infants and children, or part 
thereof)
     CPT code 15365 (Tissue cultured allogeneic dermal 
substitute, face, scalp, eyelids, mouth neck, ears, orbits, genitalia, 
hands, feet and/or multiple digits; first 100 sq cm or less, or one 
percent of body area of infants and children)
     CPT code 15366 (Tissue cultured allogeneic dermal 
substitute, face, scalp, eyelids, mouth neck, ears, orbits, genitalia, 
hands, feet and/or multiple digits; first 100 sq cm or less, or one 
percent of body area of infants and children)
     CPT code 15420 (Xenograft skin (dermal), for temporary 
wound closure, face, scalp, eyelids, mouth neck, ears, orbits, 
genitalia, hands, feet and/or multiple digits; first 100 sq cm or less, 
or one percent of body area of infants and children)
     CPT code 15421 (Xenograft skin (dermal), for temporary 
wound closure, face, scalp, eyelids, mouth neck, ears, orbits, 
genitalia, hands, feet and/or multiple digits; each additional 100 sq 
cm, or each additional one percent of body area of infants and 
children, or part thereof)
     CPT code 15430 (Acellular xenograft implant; first 100 sq 
cm or less, or one percent of body area of infants and children)
     CPT code 15431 (Acellular xenograft implant; each 
additional 100 sq cm, or each additional one percent of body area of 
infants and children, or part thereof).
    The CY 2006 interim final APC assignments of these codes, the 
recommendations made by the APC Panel at its March 2006 meeting, and 
our proposed placement of the codes for CY 2007 were listed in Table 11 
of the CY 2007 OPPS proposed rule (71 FR 49557). As noted in the 
proposed rule, in general, biological skin substitutes and replacements 
used in procedures described by these CPT codes were proposed for 
separate payment under the OPPS for CY 2007, according to the 
methodology outlined in section V. of the preamble of the proposed rule 
(71 FR 49557) and discussed in this preamble.
    As we indicated in the proposed rule (71 FR 49558), we reviewed the 
presentations to the APC Panel; the APC Panel's recommendations; the 
CPT code descriptors, introductory explanations, cross-references, and 
parenthetical notes; the clinical characteristic of the procedures; and 
the code-specific median costs for all related CPT codes available from 
our CY 2005 claims data. While we agreed with the APC Panel that the 
codes currently placed in APC 0024 (Level I Skin Repair) should be 
assigned to an APC with a higher median cost for CY 2007, we disagreed 
that these procedures should be placed in APC 0027 (Level IV Skin 
Repair). The APC Panel presenters reasoned that some of the codes (CPT 
codes 15170, 15175, 15320, 15340, 15360, 15365, 15420, and 15430) for 
the first increment of body surface area treated should be placed in 
APC 0027 because they are similar to CPT code 15300 (Allograft skin for 
temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or 
one percent of body area of infants and children). Upon further review 
of the clinical and expected hospital resource characteristics of CPT 
code 15300, we asserted in the proposed rule that this procedure was 
not appropriately placed in APC 0027. Split-thickness and full 
thickness skin autograft procedures currently assigned to APC 0027 were 
likely to require greater hospital resources, including additional 
operating room time and special equipment, in comparison to application 
of a separately paid allograft skin product. Instead, for CY 2007 we 
proposed to reassign CPT code 15300 to APC 0025 (Level II Skin Repair), 
with an APC median cost of $314.58. We agreed, in principle, that other 
CPT codes for the first increment of body surface area treated with a 
skin replacement or skin substitute were similar clinically and from a 
hospital resource perspective to CPT code 15300 and, therefore, we

[[Page 68056]]

proposed to assign these procedures to APC 0025 as well for CY 2007.
    Similarly, presenters reasoned that the related add-on codes (CPT 
codes 15171, 15176, 15321, 15342, 15361, 15366, 15421, and 15431) for 
procedures to treat additional body surface areas are similar to CPT 
code 15301 (Allograft skin for temporary wound closure, trunk, arms, 
legs; each additional 100 sq cm, or each additional one percent of body 
area of infants and children, or part thereof) in terms of required 
hospital resources. CPT code 15301 is assigned to APC 0025 for CY 2006. 
We proposed to maintain the assignment of CPT code 15301 to APC 0025 
for CY 2007 and to reassign the other add-on codes to this APC. Note 
that APC 0025 has a status indicator of ``T,'' so that the add-on codes 
would experience the standard OPPS multiple surgical procedure 
reduction when properly billed with the first body surface area 
treatment codes that are assigned to the same clinical APC. We asserted 
in the proposed rule that this reduction in payment for the procedural 
resources associated with the add-on services was appropriate. (71 FR 
49558).
    The APC Panel did not hear any presentations or make any 
recommendations regarding skin substitutes or skin replacement codes 
and APCs at its August 2006 meeting.
    Comment: One commenter on the CY 2006 final rule requested that we 
reassign CPT codes 15340 and 15341 to APC 0025, where the services 
would be grouped with clinically related services that require 
comparable hospital resources. In particular, the commenter noted that 
APC 0024 did not provide appropriate payment for the costs of surgical 
debridement of the wound to prepare it properly for application of the 
allogeneic skin substitute. Several commenters on the CY 2007 proposed 
rule supported our proposal to assign new CPT codes 15340 and 15341 to 
APC 0025. One commenter noted that the proposed assignments of these 
CPT codes for tissue cultured allogeneic skin substitutes to APC 0025 
for CY 2007 would correct substantial reductions in payment for 
application of one product that occurred with the assignment of these 
CPT codes to APC 0024 for CY 2006. The commenter believed that our 
proposal represented a significant step toward the appropriate payment 
for these services. The commenter further claimed that its external 
analyses of Medicare claims data supported the change, with a median 
cost for new CPT code 15340 that was higher than the median cost of APC 
0025 but lower than the median cost of APC 0027.
    Response: We appreciate the recognition from the commenter that the 
proposed assignments of CPT codes 15340 and 15341 to APC 0025 provides 
more appropriate payment for these services.
    Comment: A commenter supported our CY 2007 proposed assignments of 
CPT codes 15170 through 15176, 15300-15321, 15340-15366, and 15420-
15431 to APC 0025. One commenter agreed that skin substitute or 
replacement add-on codes (CPT codes 15171, 15176, 15301, 15321, 15341, 
15361, 16366, 15421, and 15431) should be placed in APC 0025. Another 
commenter provided significant clinical detail about dermal replacement 
services, described by CPT codes 15170 through 15176, and about 
temporary wound closure by allograft services, described by CPT codes 
15300 through 15321. In contrast to our proposal, the commenters 
believed that, based on the clinical characteristics and expected costs 
including anesthesia, procedure room time, supplies, and preparation of 
the products for application, these services would be most 
appropriately assigned to APC 0686 (Level III Skin Repair). They 
believed that CMS had underestimated the resources required to perform 
these procedures.
    Response: While the commenters provided comparisons among the 
expected relative costs of various procedures, the commenter provided 
no specific cost analyses to persuade us to assign CPT codes 15170 
through 15176 and 15300 through 15321 to a skin repair APC that would 
provide payment at two and a half times the proposed payment rate for 
these services. We do not agree that the clinical and resource 
distinctions between these procedures and other services also assigned 
to APC 0025 would warrant their reassignment to APC 0686, with its 
significantly higher payment rate than their CY 2007 proposed payment 
rate. We note that we will have claims data for all of these CPT codes 
available for the CY 2008 OPPS update.
    After carefully considering the public comments received, we are 
finalizing our proposed assignments of skin substitute and skin 
replacement procedures as shown in Table 16 below without modification.
BILLING CODE 4120-01-P

[[Page 68057]]

[GRAPHIC] [TIFF OMITTED] TR24NO06.017

BILLING CODE 4120-01-C
b. Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064)
    APC 0046 (Open/Percutaneous Treatment Fracture or Dislocation) was 
a large clinical APC to which many procedures related to the 
percutaneous or open treatment of fractures and dislocations are 
assigned for CY 2006. Most of the approximately 100 procedures in the 
APC are relatively low volume, with even fewer single bills available 
for ratesetting. The median costs of the significant procedures in this 
APC as configured for CY 2006 range from a low of about $1,415 to a 
high of about $3,893. We received comments to the CY 2006 proposed rule 
(70 FR 42674) requesting that we distinguish procedures containing 
``with or without external fixation'' in their descriptors to provide 
greater payments when external fixation is used to treat fractures. The 
commenters explained that when external fixation devices are used, the 
costs of the procedures increase, and, therefore, the current APC 
placement significantly underpays those procedures in those instances. 
In the CY 2006 final rule with comment period (70 FR 68607), we 
declined to reassign procedures that could include external fixation at 
that time but we acknowledged that we had treated APC 0046 as an 
exception to the 2 times rule for several years. For CY 2006, we again 
treated APC 0046 as an exception to the 2 times rule, but noted we 
would ask the APC Panel to consider whether this APC could be 
reconfigured to improve its clinical and resource homogeneity.
    At the March 2006 meeting of the APC Panel, we asked the Panel to 
consider a possible reconfiguration of APC 0046 based on partial year 
CY 2005 claims data. The reconfiguration would create three new APCs 
and would divide the codes in APC 0046 among

[[Page 68058]]

them. The APC Panel recommended that CMS continue to evaluate the 
refinement of APC 0046 into at least three APC levels, with 
consideration of a fourth level should data support this additional 
level. We accepted the APC Panel's recommendation and proposed for CY 
2007 to split APC 0046 into three new APCs: APC 0062 (Level I Treatment 
Fracture/Dislocation); APC 0063 (Level II Treatment Fracture/
Dislocation); and APC 0064 (Level III Treatment Fracture/Dislocation). 
To ensure clinical and resource homogeneity in the new APCs, their 
proposed configurations were based on the procedure code descriptors, 
clinical considerations specific to each procedure, and service-
specific hospital resource utilization as shown in the claims data from 
CY 2005. Restructuring APC 0046 into these three new APCs eliminated 2 
times rule violations in the Fracture/Dislocation series.
    The APC Panel did not hear any presentations or make any 
recommendations regarding APC 0046 or our proposed APCs 0062, 0063, and 
0064 at its August 2006 meeting.
    We did not propose a fourth APC level in the Fracture/Dislocation 
series because we did not believe our claims data were sufficiently 
robust and consistent from year to year to support differential payment 
for another service level. One code, CPT 27615 (Radical resection of 
tumor (e.g., malignant neoplasm), soft tissue of leg or ankle area), 
was not clinically coherent with the other procedures in APC 0046, and 
we proposed to reassign this procedure outside of the Fracture/
Dislocation series to APC 0050 (Level II Musculoskeletal Procedures 
Except Hand and Foot) for CY 2007.
    We received two supportive comments on our proposed reconfiguration 
of APC 0046. A summary of the comments and our response follow:
    Comment: A few commenters supported our proposal to move from one 
APC (0046) to three APCs (0062, 0063, and 0064) for services that treat 
fractures and dislocations. The commenters noted that three APCs better 
recognize the differences in hospital resource utilization. The 
commenters noted that OPPS payments would increase significantly for 
the highest level of fracture and dislocation treatment, decrease for 
the lowest level, and remain relatively stable for the medium treatment 
level.
    Response: We appreciate the acknowledgement that we are attempting 
to better recognize the differences in hospital resource utilization 
for fracture and dislocation procedures.
    We note that AMA's CPT Editorial Panel has deleted CPT 25611 
(Percutaneous skeletal fixation of distal radial fracture (e.g., Colles 
or Smith type) or epiphyseal separation, with or without fracture of 
ulnar styloid, requiring manipulation, with or without external 
fixation) for CY 2007, replacing it with CPT code 25606 (Percutaneous 
skeletal fixation of distal radial fracture or epiphyseal separation). 
AMA's CPT Editorial Panel has also deleted CPT code 25620 (Open 
treatment of distal radial fracture (e.g., Colles or Smith type) or 
epiphyseal separation, with or without fracture of ulnar styloid, with 
or without internal or external fixation) for CY 2007, replacing it 
with three CPT codes as refinements: CPT code 25607 (Open treatment of 
distal radial extraarticular fracture or epiphyseal separation, with 
internal fixation); CPT code 25608 (Open treatment of distal radial 
intraarticular fracture or epiphyseal separation; with internal 
fixation of two fragments); and CPT code 25609 (Open treatment of 
distal radial intraarticular fracture or epiphyseal separation; with 
internal fixation of three or more fragments). These changes are 
effective January 1, 2007. The interim final APC assignments of the new 
CY 2007 CPT codes for fracture treatments are included in Table 17 
below.
    After carefully considering the comments received, we are 
finalizing our proposal without modification to reconfigure CY 2006 APC 
0046 for fracture and dislocation procedures into three new APCs for CY 
2007, APCs 0062, 0063, and 0064, as displayed in Table 17, and to 
reassign CPT code 27615 to APC 0050.

                 Table 17.--Reconfiguration of APC 0046
------------------------------------------------------------------------
                                                                CY 2007
            HCPCS  code                    Description            APC
------------------------------------------------------------------------
21336.............................  Treat nasal septal              0063
                                     fracture.
21805.............................  Treatment of rib fracture       0062
23515.............................  Treat clavicle fracture..       0064
23530.............................  Treat clavicle                  0063
                                     dislocation.
23532.............................  Treat clavicle                  0062
                                     dislocation.
23550.............................  Treat clavicle                  0063
                                     dislocation.
23552.............................  Treat clavicle                  0063
                                     dislocation.
23585.............................  Treat scapula fracture...       0064
23615.............................  Treat humerus fracture...       0064
23616.............................  Treat humerus fracture...       0064
23630.............................  Treat humerus fracture...       0064
23660.............................  Treat shoulder                  0063
                                     dislocation.
23670.............................  Treat dislocation/              0064
                                     fracture.
23680.............................  Treat dislocation/              0063
                                     fracture.
24515.............................  Treat humerus fracture...       0064
24516.............................  Treat humerus fracture...       0064
24538.............................  Treat humerus fracture...       0062
24545.............................  Treat humerus fracture...       0064
24546.............................  Treat humerus fracture...       0064
24566.............................  Treat humerus fracture...       0062
24575.............................  Treat humerus fracture...       0064
24579.............................  Treat humerus fracture...       0064
24582.............................  Treat humerus fracture...       0062
24586.............................  Treat elbow fracture.....       0064
24587.............................  Treat elbow fracture.....       0064
24615.............................  Treat elbow dislocation..       0064
24635.............................  Treat elbow fracture.....       0064
24665.............................  Treat radius fracture....       0063

[[Page 68059]]

 
24666.............................  Treat radius fracture....       0064
24685.............................  Treat ulnar fracture.....       0063
25515.............................  Treat fracture of radius.       0063
25525.............................  Treat fracture of radius.       0063
25526.............................  Treat fracture of radius.       0063
25545.............................  Treat fracture of ulna...       0063
25574.............................  Treat fracture radius &         0064
                                     ulna.
25575.............................  Treat fracture radius/          0064
                                     ulna.
25606 (25611 deleted).............  Treat fx distal radial...       0062
25607 (25620 deleted).............  Treat fx rad extra-             0064
                                     articul.
25608 (25620 deleted).............  Treat fx rad intra-             0064
                                     articul.
25609 (25620 deleted).............  Treat fx radial 3+ frag..       0064
25628.............................  Treat wrist bone fracture       0063
25645.............................  Treat wrist bone fracture       0063
25651.............................  Pin ulnar styloid               0062
                                     fracture.
25652.............................  Treat fracture ulnar            0063
                                     styloid.
25670.............................  Treat wrist dislocation..       0062
25671.............................  Pin radioulnar                  0062
                                     dislocation.
25676.............................  Treat wrist dislocation..       0062
25685.............................  Treat wrist fracture.....       0062
25695.............................  Treat wrist dislocation..       0062
26608.............................  Treat metacarpal fracture       0062
26615.............................  Treat metacarpal fracture       0063
26650.............................  Treat thumb fracture.....       0062
26665.............................  Treat thumb fracture.....       0063
26676.............................  Pin hand dislocation.....       0062
26685.............................  Treat hand dislocation...       0063
26686.............................  Treat hand dislocation...       0064
26715.............................  Treat knuckle dislocation       0063
26727.............................  Treat finger fracture,          0062
                                     each.
26735.............................  Treat finger fracture,          0063
                                     each.
26746.............................  Treat finger fracture,          0063
                                     each.
26756.............................  Pin finger fracture, each       0062
26765.............................  Treat finger fracture,          0063
                                     each.
26776.............................  Pin finger dislocation...       0062
26785.............................  Treat finger dislocation.       0062
27202.............................  Treat tail bone fracture.       0063
27509.............................  Treatment of thigh              0062
                                     fracture.
27524.............................  Treat kneecap fracture...       0063
27566.............................  Treat kneecap dislocation       0063
27615.............................  Remove tumor, lower leg..       0050
27756.............................  Treatment of tibia              0062
                                     fracture.
27758.............................  Treatment of tibia              0063
                                     fracture.
27759.............................  Treatment of tibia              0064
                                     fracture.
27766.............................  Treatment of ankle              0063
                                     fracture.
27784.............................  Treatment of fibula             0063
                                     fracture.
27792.............................  Treatment of ankle              0063
                                     fracture.
27814.............................  Treatment of ankle              0063
                                     fracture.
27822.............................  Treatment of ankle              0063
                                     fracture.
27823.............................  Treatment of ankle              0064
                                     fracture.
27826.............................  Treat lower leg fracture.       0063
27827.............................  Treat lower leg fracture.       0064
27828.............................  Treat lower leg fracture.       0064
27829.............................  Treat lower leg joint....       0063
27832.............................  Treat lower leg                 0063
                                     dislocation.
27846.............................  Treat ankle dislocation..       0063
27848.............................  Treat ankle dislocation..       0063
28406.............................  Treatment of heel               0062
                                     fracture.
28415.............................  Treat heel fracture......       0063
28420.............................  Treat/graft heel fracture       0063
28436.............................  Treatment of ankle              0062
                                     fracture.
28445.............................  Treat ankle fracture.....       0063
28456.............................  Treat midfoot fracture...       0062
28465.............................  Treat midfoot fracture,         0063
                                     each.
28476.............................  Treat metatarsal fracture       0062
28485.............................  Treat metatarsal fracture       0063
28496.............................  Treat big toe fracture...       0062
28505.............................  Treat big toe fracture...       0063
28525.............................  Treat toe fracture.......       0063
28531.............................  Treat sesamoid bone             0063
                                     fracture.
28545.............................  Treat foot dislocation...       0062

[[Page 68060]]

 
28546.............................  Treat foot dislocation...       0062
28555.............................  Repair foot dislocation..       0063
28576.............................  Treat foot dislocation...       0062
28585.............................  Repair foot dislocation..       0063
28606.............................  Treat foot dislocation...       0062
28615.............................  Repair foot dislocation..       0063
28636.............................  Treat toe dislocation....       0062
28645.............................  Repair toe dislocation...       0063
28666.............................  Treat toe dislocation....       0062
28675.............................  Repair of toe dislocation       0063
------------------------------------------------------------------------

c. Complex Skin Repair (APC 0024)
    In the CY 2007 OPPS proposed rule, we proposed to assign CPT code 
13151 (Repair, complex, eyelids, nose, ears and/or lip, 1.1 cm to 2.5 
cm, to APC 0024 (Level I Skin Repair) with a payment rate of $91.86.
    Comment: One commenter asked why CPT code 13151 (Repair, complex, 
eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm) was assigned to APC 
0024, rather than to APC 0025 (Level II Skin Repair). The commenter 
pointed out that the smaller skin repair represented by CPT code 13150 
was assigned to APC 0025 with other more complex skin repair 
procedures.
    Response: We agree with the commenter that CPT code 13151 would be 
more appropriated assigned to APC 0025 and are making that reassignment 
effective January 1, 2007.
d. Insertion of Posterior Spinous Process Distraction Device
    The AMA released two new Category III codes on July 1, 2006, for 
insertion of a posterior spinous process distraction device, namely: 
0171T (Insertion of posterior spinous process distraction device 
(including necessary removal of bone or ligament for insertion and 
imaging guidance), lumbar; single level); and 0172T (Insertion of 
posterior spinous process distraction device (including necessary 
removal of bone or ligament for insertion and imaging guidance), 
lumbar; each additional level (List separately in addition to code for 
primary procedure)). These two new codes are effective January 1, 2007. 
Moreover, we have created a new device category for transitional pass-
through payment, effective January 1, 2007, C1821 (Interspinous process 
distraction device (implantable)), which we expect to be reported with 
these procedures. At its August 2006 meeting, the APC Panel recommended 
that CMS review the resources required for these new CPT codes and 
recommend appropriate APC assignments for them for CY 2007.
    Comment: Some commenters indicated that CMS should place new 
procedure codes 0171T and 0172T into clinical APC 0051 (Level III 
Musculoskeletal Procedures Except Hand and Foot). Although the level of 
resources used in performing CPT code 0172T (second and subsequent 
level implants) is less than those used for CPT code 0171T (the single 
level implant of the device), the commenters believed that APC 0051 is 
also appropriate for 0172T because APC 0051 is subject to the multiple 
procedure discount. CPT code 0172T is an add-on code to the primary 
procedure reported with CPT code 0171T; therefore, payment for 0172T 
would always be reduced by 50 percent. One commenter stated that the 
resource elements they outlined specifically for CPT code 0172T are all 
costs incurred separately and in addition to the costs of the single 
level procedure, CPT code 0171T. The commenter believed it would be 
inappropriate to place CPT code 0172T into an APC based on the claimed 
resources, and then reduce the payment rate by 50 percent when a 
multiple procedure discount applies to every case that is correctly 
coded. The commenter provided charge data from seven claims for six 
different facilities that performed the single level procedure (CPT 
code 0171T). The commenter calculated a ``median'' of these charges 
reduced to cost of $2,727, which the commenter asserted was within the 
range of median costs of other procedures assigned to APC 0051. The 
commenter stated that it was unable to obtain any facility charge or 
cost data for CPT code 0172T. The commenter acknowledged that CMS had 
also granted transitional pass-through payment status for spinous 
process distraction devices effective January 1, 2007.
    One commenter indicated that it expected the spinous process 
distraction device to remain on pass-through status through CY 2008 
and, therefore, be paid separately through that time. However, the 
commenter expressed concern that once the device is no longer paid 
separately under pass-through payment, the device costs, which would be 
a substantial percentage of total procedural costs, would be packaged 
into payment for the procedural APC and adjusted by the wage index that 
is applied to 60 percent of the payment rate. The commenter requested 
that CMS address this issue, so that once payment for the spinous 
process distraction device is packaged into the procedural APC payment, 
hospitals with wage indices below 1.0 would be able to continue 
offering the procedure to patients.
    Another commenter stated that it had performed four spinous process 
distraction device cases over the past year. All four cases had similar 
utilization patterns and outcomes. The commenter claimed to have 
evaluated the time and resources needed to complete the procedure, and 
compared the costs to other procedures, for example, laminectomies and 
diskectomies, performed at the hospital, and also extracted single 
procedure costs for all cases performed in APCs 0049 through 0052. The 
commenter determined that the costs of the four spinous process 
distraction device cases were most consistent with the costs of other 
services assigned to APC 0051.
    Response: The commenters provided their recommendation based on 
their limited cost studies that relied on information from a few 
hospitals with experience implanting spinous process distraction 
devices. This is not unusual for new procedures, such as CPT Category 
III codes. We examined the procedural resource information provided by 
commenters as well as considered CY 2005 claims data for other 
musculoskeletal procedures in the OPPS. We believe that both of the 
procedures describe by CPT codes

[[Page 68061]]

0171T and 0172T would be most appropriately assigned to APC 0050 (Level 
II Musculoskeletal Procedures Except Hand and Foot), based on both 
clinical and expected resource considerations. Their assignment to the 
same clinical APC for CY 2007 will ensure appropriate payment for CPT 
code 0172T when the multiple procedure payment reduction is applied. We 
note that the device cost of HCPCS code C1821 (Interspinous process 
distraction device (implantable)), will be paid separately under the 
OPPS for at least 2 and not more than 3 years of pass-through payment. 
After that period, payment for the cost of the device would be packaged 
into the procedural APC payments for its implantation, most likely CPT 
codes 0171T and 0172T. At that time, we will further evaluate the most 
appropriate APC assignments for these procedures, as we will each year. 
For a discussion about application of the wage index to payments for 
APCs that have significant device costs, see section IV.A.2 of this 
final rule with comment period.
    After carefully considering the public comments received, we are 
accepting the APC Panel's recommendation and assigning CPT codes 0171T 
and 0172T to APC 0050 with status indicator ``T'' for CY 2007. These 
assignments are interim final, and, therefore, open to comment in this 
final rule with comment period.
7. Medical Services
a. Medication Therapy Management Services
    Following a presentation at its March 2006 meeting, the APC Panel 
made two recommendations regarding Category III CPT codes for 
pharmacist medication therapy management services that were new for CY 
2006. These services include CPT codes 0115T (medication therapy 
management services provided by a pharmacist, individual, face-to-face 
with patient, initial 15 min., w/ assessment and intervention if 
provided; initial encounter), 0116T (medication therapy management; 
subsequent encounter), and 0117T (medication therapy management; 
additional 15 min.). These codes were assigned status indicator ``B'' 
in the CY 2006 OPPS final rule with comment period, indicating that 
they are not recognized by the OPPS when submitted on an outpatient 
hospital Part B bill type, with comment indicator ``NI'' to identify 
them as subject to comment. The APC Panel recommended that CMS create a 
new APC, with a nominal payment, to which we would assign these codes; 
implement the assignment in July 2006, if possible, or otherwise in CY 
2007; and provide guidance to hospitals on how and when these codes 
should be reported. As indicated in the CY 2007 OPPS proposed rule (71 
FR 49563), we did not accept the APC Panel's recommendations. Rather, 
we proposed to continue to assign status indicator ``B'' to CPT codes 
0115T, 0116T, and 0117T for CY 2007.
    According to the AMA, the purpose of Category III CPT codes is to 
facilitate data collection on and assessment of new services and 
procedures. Medication therapy management services are not new services 
in the OPPS, as they have been provided to patients by hospitals in the 
past as components of a wide variety of services provided by hospitals, 
including clinic and emergency room visits, procedures, and diagnostic 
tests. As such, in the CY 2007 proposed rule, we noted that we believe 
their associated hospital resource costs were already incorporated into 
the OPPS payments for these other services that are based on historical 
hospital claims data. The three Category III CPT codes specifically 
describe medication therapy management services provided by a 
pharmacist. We indicated that we had no need to distinguish medication 
therapy management services provided by a pharmacist in a hospital from 
medication therapy management services provided by other hospital 
staff, as the OPPS only makes payments for services provided incident 
to physicians' services. Hospitals providing medication therapy 
management services incident to physicians' services may choose a 
variety of staffing configurations to provide those services, taking 
into account other relevant factors such as State and local laws and 
hospital policies.
    In the CY 2007 proposed rule, we explained that in general, we do 
not establish new clinical APCs for new codes and set payment rates for 
those APCs when we have no cost data for any services populating the 
APCs. New codes for which we believe that there are no existing 
clinical APCs compatible with their expected clinical and hospital 
resource characteristics are often assigned to New Technology APCs 
until we have sufficient cost data to determine appropriate clinical 
APC assignments. However, these medication therapy management codes 
would not be eligible to map to New Technology APCs because they are 
not new services that are unrepresented in historical hospital claims 
data. As stated earlier, because we believe the costs of medication 
therapy management services were imbedded as a component within our 
claims data, we were confident that our CY 2005 claims data reflected 
the costs of pharmacist medication management services provided to 
hospital outpatients who were receiving hospital services.
    We received a large number of public comments concerning our 
proposal for CPT codes 0115T, 0116T, and 0117. A summary of the 
comments and our responses follows:
    Comment: Most commenters requested that Medicare pay separately for 
medication therapy management because it is difficult for the hospital 
to provide this service without receiving any payment. One commenter 
elaborated on the emerging role of a pharmacist and the increasing 
scope of services provided by the pharmacist to the patient, including 
proactive assessments rather than simply reactive responses. This 
commenter stated that although the historical resource costs of the 
pharmacist's services may be captured in the claims data, it was 
unlikely that the resource costs of the new responsibilities are 
represented in the data. Another commenter quoted statistics that 
estimated that, in 2004, only 30 percent of hospitals had pharmacists 
who were involved in ambulatory care. Of those who were involved, only 
50 percent had involvement in medication therapy management services. 
Therefore, although there may be cost data embedded in the claims, the 
fact that these services have historically been provided infrequently 
means that the costs of these services have minimal impact on our 
median cost data. Many commenters noted that these pharmacist services 
reduce costs in the long run by improving the health of patients. One 
commenter agreed that these services are already accounted for in the 
claims data and further agreed that there is no need to distinguish 
between services provided by pharmacists and other providers. One 
commenter suggested that medication therapy management could be 
provided to a patient on the same day as a laboratory test and 
requested that CMS clarify the appropriate billing technique under such 
circumstances. Another commenter specifically asked if it was 
appropriate to bill CPT code 99211, the lowest level clinic visit, if 
the only service provided to a patient is medication therapy management 
by a pharmacist. One commenter agreed that these services are not 
technically new, but suggested that CMS map them to New Technology APCs 
because they are new in the sense that they are now more

[[Page 68062]]

readily available independent of a physician's service or clinic 
procedure. One pharmacy association objected to our statement that 
these services can be provided by staff other than pharmacists. The 
association notes that pharmacists have distinct training, skills, and 
abilities to perform these services, which are reflected in the new 
Category III codes.
    Response: We agree with the commenters that medication therapy 
management services are important services provided to patients and 
that providers should receive payments for these services. We would 
expect the hospital charges for the services provided to the patient to 
include charges for all hospital resource costs associated with the 
patient's care, including medication therapy management services, if 
appropriate. As we stated above, medication therapy management services 
are not new services, and they have been provided in the past as 
components of a wide variety of services provided by hospitals, 
including clinic and emergency room visits, procedures, and diagnostic 
tests. Although we do not make separate payment for medication therapy 
management provided by a pharmacist, the costs for this service are 
included in the costs of other services furnished by the hospital on 
the same day. Therefore, we continue to believe that the costs for 
these services are embedded in our claims data, and are reflected in 
our payment rates, thereby providing payments for these important 
services. While we acknowledge commenters' concerns that hospitals are 
providing medication therapy management services more frequently than 
in the past, we continue to disagree that they are new and should be 
assigned to a New Technology APC. To the extent that medical management 
services evolve over time to require more facility resources due to 
their greater complexity, we expect those higher costs to be reflected 
in hospitals' charges for the associated services, which will then 
provide the basis for future ratesetting under the OPPS.
    To clarify our billing requirements, if the only service provided 
to a patient is a laboratory test to determine medication levels, the 
laboratory test is all that should be billed. If a hospital provides a 
distinct, separately identifiable service in addition to the test, the 
hospital is responsible for billing the HCPCS code that most closely 
describes the service provided. Billing a visit code in addition to 
another service merely because the patient interacted with hospital 
staff or spent time in a room for that service is inappropriate. A 
hospital may bill a visit code, based on the hospital's own coding 
guidelines which must reasonably relate the intensity of hospital 
resources to the different levels of HCPCS codes. Services furnished 
must be medically necessary and documented.
    After carefully considering the comments received, we are 
continuing to assign status indicator ``B'' to CPT codes 0115T, 0116T, 
and 0117T for CY 2007 and finalizing our proposed policy without 
modification.
b. Single Allergy Tests (APC 0381)
    We proposed to continue with our methodology of differentiating 
single allergy tests (``per test'') from multiple allergy tests (``per 
visit'') by assigning these services to two different APCs to provide 
accurate payments for these tests in CY 2007. Multiple allergy tests 
are assigned to APC 0370 (Allergy Tests) with a median cost calculated 
based on the standard OPPS methodology. We provided billing guidance in 
CY 2006 in Transmittal 804 (issued on January 3, 2006) specifically 
clarifying that hospitals should report charges for the CPT codes that 
describe single allergy tests to reflect charges ``per test'' rather 
than ``per visit'' and should bill the appropriate number of units of 
these CPT codes to describe all of the tests provided. However, our CY 
2005 claims data available for the CY 2007 proposed rule did not yet 
reflect the improved and more consistent hospital billing practices of 
``per test'' for single allergy tests. Some claims for single allergy 
tests still appeared to provide charges that represented a ``per 
visit'' charge, rather than a ``per test'' charge. Therefore, 
consistent with our payment policy for CY 2006, we proposed to 
calculate a ``per unit'' median cost for APC 0381, based upon 349 
claims containing multiple units or multiple occurrences of a single 
CPT code, where packaging on the claims was allocated equally to each 
unit of the CPT code. Using this methodology, we calculated a median 
cost of $13.29 for APC 0381 for CY 2007. As indicated in the CY 2007 
OPPS proposed rule (71 FR 49566), we were hopeful that the better and 
more accurate hospital reporting and charging practices for these 
single allergy test CPT codes beginning in CY 2006 would allow us to 
calculate the median cost of APC 0381 using the standard OPPS process 
in future OPPS updates.
    We did not receive any public comments concerning our proposed 
methodology for differentiating single allergy tests from multiple 
allergy tests for OPPS payment in CY 2007. The final CY 2007 APC 0381 
median cost calculated based upon 382 single claims, using the 
methodology as proposed, is $16.43.
c. Hyperbaric Oxygen Therapy (APC 0659)
    When hyperbaric oxygen therapy (HBOT) is prescribed for promoting 
the healing of chronic wounds, it typically is prescribed for 90 
minutes and billed using multiple units of HBOT on a single line or 
multiple occurrences of HBOT on a claim. In addition to the therapeutic 
time spent at full hyperbaric oxygen pressure, treatment involves 
additional time for achieving full pressure (descent), providing air 
breaks to prevent neurological and other complications from occurring 
during the course of treatment, and returning the patient to 
atmospheric pressure (ascent). The OPPS recognizes HCPCS code C1300 
(Hyperbaric oxygen under pressure, full body chamber, per 30 minute 
interval) for HBOT provided in the hospital outpatient setting.
    In the CY 2005 final rule with comment period (69 FR 65758 through 
65759), we finalized a ``per unit'' median cost calculation for APC 
0659 (Hyperbaric Oxygen) using only claims with multiple units or 
multiple occurrences of HCPCS code C1300 because delivery of a typical 
HBOT service requires more than 30 minutes. We observed that claims 
with only a single occurrence of the code were anomalies, either 
because they reflected terminated sessions or because they were 
incorrectly coded with a single unit. In the same rule, we also 
established that HBOT would not generally be furnished with additional 
services that might be packaged under the standard OPPS APC median cost 
methodology. This enabled us to use claims with multiple units or 
multiple occurrences. Finally, we also used each hospital's overall CCR 
to estimate costs for HCPCS code C1300 from billed charges rather than 
the CCR for the respiratory therapy cost center. Comments on the CY 
2005 proposed rule effectively demonstrated that hospitals report the 
costs and charges for HBOT in a wide variety of cost centers. We used 
this methodology to estimate payment for HBOT in CYs 2005 and 2006. For 
CY 2007, we proposed to continue using the same methodology to estimate 
a ``per unit'' median cost for HCPCS code C1300. Using 50,311 claims 
with multiple units or multiple occurrences, we estimated a median cost 
of $98.36 for CY 2007.
    Comment: One commenter agreed with CMS' approach to determining the 
median costs for HCPCS code C1300

[[Page 68063]]

(HBOT) to the extent that it eliminated services that were obviously 
billed incorrectly. The commenter believed that use of the hospital's 
overall CCR appeared to be the best option at this time. However, the 
commenter asked that hospitals be allowed to bill these services with 
multiple revenue codes (not just respiratory therapy), so that 
hospitals could bill the services under the revenue code that was most 
closely linked to the cost center where the services were furnished. 
The commenter also requested that the revenue code to cost center 
crosswalk be revised to reflect the use of the hospital's overall CCR 
for HBOT.
    In contrast, another commenter was concerned that CMS' claims data 
do not accurately reflect the costs of this therapy because of 
potential hospital miscoding. The commenter believed that the use of 
hospitals' overall CCRs did not reflect the relationship between costs 
and charges specific to HBOT. The commenter believed that the payment 
rate for HCPCS code C1300 continued to be inadequate as proposed for CY 
2007 and asked that the rate be increased based on the external data 
provided by an association to the APC Panel.
    Another commenter objected to erratic payment rates for HBOT over a 
period of years, particularly a drop in payment between CYs 2004 and 
2005. The commenter attributed this instability both to the confusion 
of hospitals regarding proper coding of treatment units and to CMS' 
inability to determine an appropriate CCR for HBOT because hospitals 
reported their costs under many cost centers. The commenter recommended 
that CMS use an external analysis that it indicated reproduces an 
accurate CCR for HBOT, calculated using a consistent and transparent 
methodology.
    Response: We believe that the final median cost for APC 0659 
($97.20 per unit) is an appropriate relative cost to be used to set the 
weights upon which the HBOT payment will be based.
    CY 2007 is the third year in which we have used a special 
methodology to develop the median cost for HBOT services that removed 
obviously erroneous claims and deviated from our standard methodology 
of using departmental CCRs, when available, to convert hospitals' 
charges to costs. Prior to CY 2005, our inclusion of significant 
numbers of miscoded claims in the median calculation for HBOT and our 
exclusion of the claims for multiple units of treatment, the typical 
scenario, resulted in payment rates that were artificially elevated. As 
explained earlier, beginning in CY 2005 and continuing through the 
present, we have adjusted the CCR used in the conversion of charges to 
costs for these services so that claims data would more accurately 
reflect the relative costs of the services. The median costs of HBOT 
calculated using this methodology have been reasonably stable for the 
last 3 years. We believe that this adjustment through use of the 
hospitals' overall CCRs is all that is necessary to yield a valid 
median cost for establishing a scaled weight for HBOT services.
    After carefully considering the public comments received, we are 
finalizing our proposed methodology for estimating a ``per unit'' 
median cost for HCPCS code C1300, assigned to APC 0659, without 
modification for CY 2007.
d. Guidance for Chemodenervation (APC 0215)
    For CY 2006, new CPT codes 95873 (Electrical stimulation for 
guidance in conjunction with chemodenervation) and 95874 (Needle 
electromyography for guidance in conjunction with chemodenervation) 
were provided interim final assignments to APC 0215 (Level I Nerve and 
Muscle Tests). The proposed APC assignments of the codes for CY 2007 
were unchanged.
    Comment: One commenter requested that CMS reevaluate the APC 
assignments for CPT codes 95873 and 95874 when data become available. 
The commenter believed that it would be appropriate to assign the codes 
to two different payment levels based on their different resource 
requirements, but the commenter understood the CMS decision to assign 
them both to one APC pending data development.
    Response: We appreciate the commenter's request, and we will 
reevaluate the assignment for both of the new codes for the CY 2008 
update to the OPPS.
    After carefully considering the public comment received, we are 
finalizing our proposal to assign CPT codes 95873 and 95874 to APC 0215 
for CY 2007, without modification.
e. Pathology Services (APC 0344)
    In Addendum B of the CY 2007 proposed rule (71 FR 49709), we 
proposed to assign a payment rate of $49.90 to APC 0344 (Level IV 
Pathology Services).
    Comment: Many commenters considered the proposed payment rate for 
APC 0344 to be low, especially when compared with the MPFS payment for 
these same laboratory CPT codes that are assigned to APC 0344. Several 
commenters indicated that the payment rate of $49.90 was far below the 
level of payment necessary for performing these tests in the hospital 
outpatient settings. One commenter cautioned that the cost differential 
between the hospital OPPS and the MPFS would result in a site-of-
service differential. The commenter submitted a table showing 
differences in payments between the OPPS and the MPFS. The commenter 
believed that the payment levels for these laboratory services should 
be the same as or equal under both Medicare payment systems. The 
commenter asked that CMS establish payment equity for the same service 
furnished in these respective settings. Several commenters urged CMS to 
review the payment rate for APC 0344, and assign a payment rate that 
reflects the complexity and resource costs associated with providing 
these services.
    Response: The statutory method for calculating payment for 
physicians' practice expenses under the MPFS differs from the general 
statutory method we use for establishing payment rates in the hospital 
outpatient setting. Consequently, the application of the different 
methodologies results in different payment amounts in the two settings.
    Payment for services assigned to APC 0344 for CY 2007 will be made 
based upon the median cost of the APC, established according to the 
standard OPPS methodology from CY 2005 hospital outpatient claims. The 
median costs of individual services assigned to APC 0344 do not violate 
the 2 times rule. The claims data used to establish the APC median cost 
are stable and robust, and the APC is appropriately structured to 
include only those procedures with common clinical and resource 
features.
    After carefully considering the public comments received, we are 
finalizing the APC 0344 structure as proposed without modification. The 
final CY 2007 median cost of APC 0344 is $48.44, upon which its payment 
rate is based.

IV. OPPS Payment Changes for Devices

A. Treatment of Device-Dependent APCs

1. Background
    Device-dependent APCs are populated by HCPCS codes that usually, 
but not always, require that a device be implanted or used to perform 
the procedure. For the CY 2002 OPPS, we used external data, in part, to 
establish the device-dependent APC medians used for weight setting. At 
that time, many devices were eligible for pass-through payment. For the 
CY 2002 OPPS, we estimated that the total amount of pass-through 
payments would far exceed the limit imposed by statute. To reduce the 
amount of a pro rata adjustment to all pass-through

[[Page 68064]]

items, we packaged 75 percent of the cost of the devices, using 
external data furnished by commenters on the August 24, 2001 proposed 
rule and information furnished on applications for pass-through 
payment, into the median costs for the device-dependent APCs associated 
with these pass-through devices. The remaining 25 percent of the cost 
was considered to be pass-through payment.
    In the CY 2003 OPPS, we determined APC medians for device-dependent 
APCs using a three-pronged approach. First, we used only claims with 
device codes on the claim to set the medians for these APCs. Second, we 
used external data, in part, to set the medians for selected device-
dependent APCs by blending that external data with claims data to 
establish the APC medians. Finally, we also adjusted the median for any 
APC (whether device-dependent or not) that declined more than 15 
percent. In addition, in the CY 2003 OPPS we deleted the device codes 
(``C'' codes) from the HCPCS file because we believed that hospitals 
would include the charges for the devices on their claims, 
notwithstanding the absence of specific codes for devices used.
    In the CY 2004 OPPS, we used only claims containing device codes to 
set the medians for device-dependent APCs and again used external data 
in a 50/50 blend with claims data to adjust medians for a few device-
dependent codes when it appeared that the adjustments were important to 
ensure access to care. However, hospital device code reporting was 
optional.
    In the CY 2005 OPPS, which was based on CY 2003 claims data, there 
were no device codes on the claims and, therefore, we could not use 
device-coded claims in median calculations as a proxy for completeness 
of the coding and charges on the claims. For the CY 2005 OPPS, we 
adjusted device-dependent APC medians for those device-dependent APCs 
for which the CY 2005 OPPS payment median was less than 95 percent of 
the CY 2004 OPPS payment median. In these cases, the CY 2005 OPPS 
payment median was adjusted to 95 percent of the CY 2004 OPPS payment 
median. We also reinstated the device codes and made the use of the 
device codes mandatory where an appropriate code exists to describe a 
device utilized in a procedure. In addition, we implemented HCPCS code 
edits to facilitate complete reporting of the charges for the devices 
used in the procedures assigned to the device-dependent APCs.
    In the CY 2006 OPPS, which was based on CY 2004 claims data, we set 
the median costs for device-dependent APCs for CY 2006 at the highest 
of: (1) The median cost of all single bills; (2) the median cost 
calculated using only claims that contained pertinent device codes and 
for which the device cost is greater than $1; or (3) 90 percent of the 
payment median that was used to set the CY 2005 payment rates. We set 
90 percent of the CY 2005 payment median as a floor rather than 85 
percent as proposed, in consideration of public comments that stated 
that a 15-percent reduction from the CY 2005 payment median was too 
large of a transitional step. We noted in our CY 2006 proposed rule 
that we viewed our proposed 85 percent payment adjustment as a 
transitional step from the adjusted medians of past years to the use of 
unadjusted medians based solely on hospital claims data with device 
codes in future years (70 FR 42714). We also incorporated, as part of 
our CY 2006 methodology, the recommendation of commenters to base 
payment on medians that were calculated using only claims that passed 
the device edits. As stated in the CY 2006 OPPS final rule with comment 
period (70 FR 68620), we believed that this policy provided a 
reasonable transition to full use of claims data in CY 2007, which 
would include device coding and device editing, while better moderating 
the amount of decline from the CY 2005 OPPS payment rates.
2. CY 2007 Payment Policy
    For CY 2007, we proposed to base the device-dependent APC medians 
on CY 2005 claims, the most current data available. As stated earlier, 
in CY 2005 we reinstated the use of device codes and made the reporting 
of device codes mandatory where an appropriate code exists to describe 
a device utilized. In CY 2005, we also implemented HCPCS code edits to 
facilitate complete reporting of the charges for the devices used in 
the procedures assigned to the device-dependent APCs. We implemented 
the first set of device edits on April 1, 2005, for those APCs for 
which the CY 2005 payment rate was based on an adjusted median cost. We 
continued to take public comment on the remaining device edits after 
April 1, 2005, and implemented device edits for the remaining device-
dependent APCs on October 1, 2005. Subsequent to the implementation of 
the device edits, we received public comments that caused us to remove 
the requirement for edits for several APCs on the basis that the 
services in them do not always require the use of a device, or there 
may be no suitable device codes available for reporting all devices 
that may be used to perform the procedures.
    For example, we removed the requirement for device codes for APC 
0080 (Diagnostic Cardiac Catheterization) based on the information 
provided by hospitals that the codes assigned to this APC do not always 
require a device for which there is an appropriate HCPCS code. 
Therefore, we no longer consider this APC to be device-dependent and 
have removed it from the list of device-dependent APCs. In the case of 
some procedures assigned to other device-dependent APCs, where we 
determined that no device was required to provide a particular service 
or where there were no HCPCS codes that described all devices that 
could be used to furnish the service, we removed the requirement for a 
device code for the individual procedure code but retained the device 
requirement for other procedure codes assigned to that device-dependent 
APC.
    At its February 2006 meeting, the APC Panel recommended that CMS 
consider calculating the median costs for APCs 0107 (Insertion of 
Cardioverter Defibrillator) and 0108 (Insertion/Replacement/Repair of 
Cardioverter-Defibrillator Leads) by bypassing the line-item costs of 
CPT code 33241 (Subcutaneous removal of single or dual chamber pacing 
cardioverter-defibrillator pulse generator) and packaging the line 
item-costs of CPT codes 93640 (Electrophysiological evaluation of 
single or dual chamber pacing cardioverter-defibrillator leads 
including defibrillation threshold evaluation (induction of arrhythmia, 
evaluation of sensing and pacing for arrhythmia termination) at time of 
initial implantation or replacement) and 93641 (Electrophysiological 
evaluation of single or dual chamber pacing cardioverter-defibrillator 
leads including defibrillation threshold evaluation (induction of 
arrhythmia, evaluation of sensing and pacing for arrhythmia 
termination) at time of initial implantation or replacement; with 
testing of single or dual chamber pacing cardioverter-defibrillator) 
when these codes, separately or in combination, are reported on the 
same claim with HCPCS codes G0297 (Insertion of single chamber pacing 
cardioverter defibrillator pulse generator), G0298 (Insertion of dual 
chamber pacing cardioverter defibrillator pulse generator), G0299 ( 
Insertion or repositioning of electrode lead for single chamber pacing 
cardioverter defibrillator and insertion of pulse generator), and G0300 
(Insertion or repositioning of electrode lead(s) for dual chamber 
pacing cardioverter defibrillator and insertion

[[Page 68065]]

of pulse generator), which are assigned to APCs 0107 and 0108. The APC 
Panel recommended bypassing the line-item costs for CPT code 33241 
because members believed that when a pacing cardioverter-defibrillator 
(ICD) pulse generator removal is performed in the same operative 
session as the insertion of a new pulse generator described by a 
procedure code assigned to APC 0107 or APC 0108, the packaging on the 
claim is appropriately assigned to the procedure code in APC 0107 or 
APC 0108. Moreover, CPT codes 93640 and 93641 may only be correctly 
coded when the electrophysiologic evaluation of ICD leads is performed 
at the time of initial implantation or replacement of an ICD pulse 
generator and/or leads, with or without testing of the pulse generator. 
Thus, the APC Panel expected that the costs of the evaluations of the 
ICD leads (CPT codes 93640 and 93641) could be appropriately packaged 
with the procedure codes that describe the insertion of ICD generators, 
which are assigned to APCs 0107 and 0108, or the insertion of ICD leads 
assigned to APCs 0106 (Insertion/Replacement/Repair of Pacemaker and/or 
Electrodes), 0108, and 0418 (Insertion of Left Ventricular Pacing 
Elect). Because APCs 0107 and 0108 have typically had very few single 
bills on which the medians have been based, and because the APC Panel 
indicated that it believed that we could use many more claims if we 
bypassed CPT code 33241 and packaged CPT codes 93640 and 93641, we 
calculated median costs for APCs 0107 and 0108 using these rules. We 
excluded claims that did not meet the device edits, and we also 
excluded token claims.
    The effect of packaging CPT codes 93640 and 93641 into claims that 
both passed the device edits and contained no token charges for devices 
were shown in Table 19 of the CY 2007 OPPS proposed rule (71 FR 49573) 
and below. This affected APCs 0106, 0107, 0108, and 0418. Bypassing the 
line-item cost of CPT code 33241 could not be done for all claims on 
which this CPT code was reported because there are clinical 
circumstances in which the ICD pulse generator is removed and no new 
device is implanted. Therefore, the APC assignment of CPT code 33241 
and the payment for that code need to reflect the packaging associated 
with the procedure when it is performed alone. Because of this problem 
with assigning packaging in all of the circumstances in which the 
procedure may be reported, we decided against proposing to bypass CPT 
code 33241, either in general for all procedures or selectively, when 
it is reported with the procedures in APCs 0107 and 0108.
    However, CPT codes 93640 and 93641 are always performed during an 
operative procedure for ICD initial implantation or replacement or with 
implantation, revision or replacement of leads, and, therefore, we 
believed that it would be appropriate to package them into the surgical 
procedure with which they are performed. Moreover, as a result of the 
descriptors of the lead evaluation CPT codes, they should never be 
billed as single procedure claims, and packaging them would also 
resolve the problem of setting their payment rates in part on the basis 
of claims that reflect erroneous coding. As we noted in the CY 2007 
proposed rule, packaging the costs of intraoperative electrophysiologic 
testing of the ICD leads yielded many more single bills on which to set 
median costs and also increased the median costs for APCs 0106, 0107, 
0108, and 0418. Therefore, we proposed to package CPT codes 93640 and 
93641 for CY 2007.
    Furthermore, the APC Panel, at its August 2006 meeting, recommended 
that CMS use readily available external data to validate the costs 
derived from claims data. While CMS reviews all information that comes 
to our attention, we have not systematically used external data to 
validate the median costs derived from our claims data, because 
external data are typically furnished by parties with special interest 
in a particular item or service. Therefore, it is of limited usefulness 
in determining the relative cost of all items and services paid under 
the OPPS. In a system of relative weights, it is the relativity of the 
costs of services to one another, as derived from a standardized system 
that uses standardized inputs and a consistent methodology, that is the 
foundation of the system. The relationship between the actual 
acquisition cost of a particular item or service compared to the 
relative cost derived from the standard system for a single item or 
service is of little value.
    For the proposed rule, we calculated the median cost for device-
dependent APCs using two different sets of claims. We first calculated 
a median cost using all single procedure claims for the procedure codes 
in those APCs. We also calculated a second median cost using only 
claims that contain allowed device codes and also for which charges for 
all device codes were in excess of $1.00 (nontoken charge device 
claims). We excluded claims for which the charge for a device was less 
than $1.01, in part, to recognize hospital charging practices due to a 
recall of cardioverter defibrillator and pacemaker pulse generators in 
CY 2005 for which the manufacturers provided replacement devices 
without cost to the beneficiary or hospital. We also found that there 
were other devices for which the charge was less than $1.01, and we 
removed those claims also.
    As expected, the median costs calculated using all single procedure 
bills, including both bills that lacked appropriate device codes (where 
there are edits) and bills with token charges for devices, were in many 
cases less than the medians calculated using only claims that contained 
appropriate device codes without token charges for the devices. In some 
cases, the medians were significantly different when claims either 
without device codes or which had only token device charges were 
removed. In the CY 2007 proposed rule, we noted that we believed that 
the claims that reflected the best estimated costs for these APCs, 
including the costs of the devices, were those claims that contain 
appropriate device codes without token charges for devices. (See 
section IV.A.4. below for our discussion of payments when the hospital 
incurs no cost for the principal device required for the service.)
    Therefore, we proposed to base the payment rates for CY 2007 for 
these device-dependent APCs on median costs calculated using claims 
with appropriate device codes with no token charges for devices 
reported on the claim. We did not believe that adjustment of these 
median costs was necessary to provide adequate payment for these 
services, and, therefore, we did not propose to adjust the median costs 
for these APCs to moderate any decreases in medians from CY 2006 to CY 
2007. However, we noted in the proposed rule that, notwithstanding the 
device edits, it may continue to be necessary for purposes of median 
cost calculations to remove claims that do not contain devices because 
it is likely that there would be incidental occurrences of interrupted 
procedures in which a device is not used and does not appear on the 
claim. (The interrupted procedure modifier nullifies the device edit.) 
Moreover, we noted that there are likely to continue to be incidental 
occurrences of token charges for devices as a result of devices that 
are replaced without cost by the manufacturer. However, each of these 
circumstances could cause the procedure code median cost to 
underrepresent the cost of the complete procedure, including the device 
cost, where the hospital purchases the device.
    Therefore, we proposed that use of claims that met the device edits 
and that

[[Page 68066]]

did not contain token charges for devices were the appropriate claims 
to use to set the median costs for the device-dependent APCs, ensuring 
that the costs of the principal devices were included in the APC 
medians. In addition, we proposed that, with our proposed changes to 
the OPPS packaging status of two codes for electrophysiologic 
evaluation of ICD leads, no special payment policies would be needed to 
establish payment rates that correctly reflect the relative costs of 
these procedures to other procedures paid under the OPPS.
    We received a number of public comments concerning our CY 2007 
proposed payment policies for device-dependent APCs.
    Comment: The commenters supported limiting the set of claims used 
to calculate median costs for device-dependent APCs to claims that 
passed the device edits and did not contain device charges less than 
$1.01 to calculate median costs. In addition, some commenters asked CMS 
to remove claims with residual charges in cases in which recalled 
devices were replaced by upgraded devices or a different type of 
device, as was done when we removed token charge claims, so that the 
full cost of the device would be wholly represented in the procedure 
claims used for ratesetting. Several commenters objected to the 
proposed payment rates on the basis that hospitals report the units and 
charges for devices incorrectly, leading to incomplete and inaccurate 
claims data. They also believed that the CMS methodology of applying 
CCRs to charges for device-intensive services results in median costs 
that do not reflect the true relative costs of those services. They 
believed that hospitals do not mark up their charges for high cost 
items sufficiently to result in the actual cost of the item, a 
phenomenon generally known as ``charge compression.'' The commenters 
stated that hospitals are inhibited by market and other forces from 
charging at a level necessary for the application of the CCR to result 
in an accurate estimate of the cost of the device. Some commenters 
offered specific statistical strategies for calculation of adjustment 
factors that could be applied to the charges for devices to overcome 
the effects of charge compression. The commenters urged CMS to examine 
these strategies for their potential application to calculation of 
median costs and to use the charge compression analysis currently 
underway for Medicare inpatient billings to initiate a similar analysis 
for Medicare outpatient hospital payments. They indicated that the 
proposed payment rates for device-dependent APCs would set payments at 
such a low level that hospitals were likely to cease furnishing these 
services so that beneficiaries would no longer have access to needed 
care. The commenters urged CMS to use external data in place of median 
costs derived from claims data and to protect all such external data 
used for ratesetting from public disclosure.
    Response: We continue to believe that it is appropriate to 
calculate the median costs to be used for establishing the payment 
rates in CY 2007 for device-dependent APCs using only claims that do 
not contain token charges for devices and that contain the devices that 
are appropriate for the procedure code, where there are HCPCS codes for 
such devices. We proposed to exclude all claims containing token 
charges because there were a number of actions in CY 2005 (the year of 
claims being used for the CY 2007 OPPS update) that caused hospitals to 
replace devices that they received without cost from manufacturers, and 
we advised hospitals to report a token charge for these devices. We 
will reassess whether exclusion of token charges is necessary for 
future years because, effective January 1, 2006, devices furnished 
without cost to the provider will be identified with modifier ``FB'' 
and exclusion of claims with token charges may no longer be necessary. 
We proposed to exclude claims that did not contain appropriate devices, 
as defined by the device edits on the CMS Web site, to maximize the 
likelihood that we would be basing the median costs for device-
dependent APCs on claims that contained the full charge for the 
service, including the device. However, we did not exclude claims that 
contained residual charges for upgrades of replaced devices for which 
hospitals received credits from manufacturers because it was not 
possible to identify them systematically. Moreover, because we are 
calculating a median cost and commenters inform us that upgraded 
devices represent only 10 to 15 percent of cases in which devices are 
replaced without cost or with credit for the replaced device, we 
believe that those claims would have minimal influence on the 
calculation of the device-dependent APC median cost used for 
ratesetting. By basing weights on the median cost where the median is 
the 50th percentile of the array, a relatively small number of 
unusually low values (as would likely be represented by 10 to 15 
percent of a relatively small number of devices replaced without any or 
full cost) is not likely to significantly affect the median cost. We 
recognize that the use of the hospital's CCR, even at the departmental 
level, results in computed costs and relative weights that may be more 
or less than the actual costs for items in specific cases. We believe 
that this average is appropriate and inherent in PPS. One of the 
principles behind the use of median costs for weight setting in a 
budget neutral payment system like the OPPS is to determine the 
appropriate relativity in resource use among services, thus allowing 
fair and equitable distribution of payment among hospitals based on 
their mix of services provided to Medicare beneficiaries. The median 
costs are not intended to represent the actual acquisition costs of the 
services being furnished. They are estimated relative costs that are 
converted to relative weights, scaled for budget neutrality and then 
multiplied by a conversion factor to derive a payment under a PPS and 
are not intended to pay reasonable costs. For this reason, we believe 
that it is not appropriate to use external pricing information in place 
of the costs derived from the claims and Medicare cost report data, 
because we believe that to do so would distort the relativity that is 
so important to the system's integrity. Similarly, we do not believe 
that it is appropriate to remove specific claims from contributing to 
ratesetting if the hospital charge for a particular item does not 
exceed an established threshold.
    However, we recognize that there may be value in exploring the 
extent to which the estimated relative costs derived from claims and 
cost report data deviate so substantially from acquisition costs that 
payment adjustments may be appropriate. Therefore, we are interested in 
further studying the analytic technique suggested in the comments that 
would involve the use of a regression analysis to identify adjustments 
that could be made to the CCRs to account for charge compression. We 
note that the regression model furnished with some comments was only 
applied to expensive medical supplies and devices. It was not applied 
uniformly to develop potential adjustments that could be made to costs 
and charges across all revenue codes and cost centers that could 
potentially be subject to charge compression. If such a model were to 
be applied in the OPPS, we believe further analysis would have to be 
undertaken to determine whether it should apply to all costs and cost 
centers. At this time, we intend to study whether a rigorous model 
could provide a payment adjustment for charge compression to the extent 
it exists.

[[Page 68067]]

    We recognize that the issues the commenters raise regarding charge 
compression apply both to the OPPS weight setting and to the setting of 
the DRG weights that are an important determinant of payment under the 
IPPS for inpatient hospital services. Accordingly, CMS has awarded a 1-
year contract to RTI International to study methods of improving 
estimates of the cost of Medicare inpatient hospital discharges used in 
constructing the DRG relative weights. The RTI contract will focus on 
methods of improving the accuracy of the adjustment of charges to cost 
to account for the fact that hospitals tend to mark up high cost items 
to a lesser extent than they mark up low cost items, the phenomenon 
known as charge compression. The study will also examine how charge 
compression interacts with other variables in the construction of the 
DRG relative weights, such as the number of cost centers included and 
whether hospital-specific relative values are used. To the extent that 
we find charge compression exists, we will further study potential 
models that could adjust for it so we might develop a more accurate 
system of cost-based weights to better reflect the relative costs of 
the different types of services provided under the OPPS. We plan to 
fully involve appropriate stakeholders in future analysis of this issue 
to the extent feasible. Before implementing such an adjustment, we 
would thoroughly describe our analysis and a potential proposed 
adjustment as part of the OPPS rulemaking process. Further, we intend 
to use the charge compression study that we will conduct over the next 
year as an opportunity to better understand the costs of medical 
devices.
    With regard to the comment that providers are ceasing to provide 
services that require devices, we have no data that causes us to 
believe that there is a problem with access to care. In fact, the 
volume and intensity of OPPS services are growing significantly each 
year. As we indicated in section XIX. of this final rule with comment 
period, Medicare program payment under the OPPS is expected to reach 
$32.54 billion in CY 2007, an increase of approximately 9 percent from 
the projected program payment of $29.809 billion in CY 2006.
    Comment: A number of commenters urged CMS to make adjustments to 
the CY 2007 payment rates for device-dependent APCs to account for 
charge compression. Specifically, some commenters recommended that CMS 
set the APC payment rates based on the higher of the median cost 
calculated using only claims that contain appropriate devices and do 
not contain token charges for devices or 90 percent of the CY 2006 
payment median because to do otherwise would result in discontinuation 
of some services that require high cost devices. Other commenters urged 
CMS to set the median cost at no less than 100 percent of the CY 2006 
median cost plus the market basket update for CY 2007. Some commenters 
believed CMS should use only claims on which the charges for their 
devices equaled or exceeded minimum thresholds that would be set based 
on amounts they specified. In several cases, the commenters asked that 
CMS do this due to the billing of residual charges for upgraded devices 
that replaced recalled devices. In other cases, they recommended 
thresholds because they believed that hospital charges for devices were 
too low, thereby resulting in inadequate APC median costs for 
establishing the CY 2007 payment rates for device-dependent procedures 
and their packaged devices.
    Response: We do not believe that it is necessary or appropriate to 
set the median cost for these device-dependent APCs at 100 percent of 
the CY 2006 payment median plus the update factor or at 90 percent of 
the CY 2006 payment median, or to otherwise override the estimated 
median costs derived from the claims process proposed, using only 
claims that contained device codes where appropriate and that did not 
contain token charges. Because the devices that are required for many 
of these services came off pass-through payment in CY 2003, we have 
implemented device edits to maximize the likelihood that the charges 
for the devices are included on the claim. Over the past several years, 
we provided for adjustments to the median costs of device-dependent 
APCs where the cost data for the OPPS update resulted in a decline in 
the median from one year to the next. We indicated in the CY 2006 final 
rule (70 FR 68620) that we fully expected to be able to transition to 
full use of the claims data without adjustment for CY 2007. We see no 
reason why we should limit the decrease in CY 2007 median cost for 
those APCs for which the median cost declines compared to the adjusted 
CY 2006 payment median cost. The nature of a payment system that is 
based on relative weights is that the weights vary from year to year. 
Any change in the median cost for an APC, whether one with a high 
device cost or not, is a function of many complex factors, including, 
but not limited to, the extent to which hospitals increase charges for 
some items and services at a different rate than charges for other 
items and services. As such, the median cost of any particular item or 
service is largely a function of both its costs and the various 
charging practices of the hospitals that bill the services. Hospitals 
have now had 6 years experience with the OPPS, 4 of which were after 
the expiration of pass-through payments for most devices. We believe 
that hospitals make thoughtful decisions regarding how they want to 
report and charge for device-dependent procedures in the context of the 
effects of those decisions on their payments by Medicare and other 
payers.
    Comment: Some commenters objected to the application of the wage 
index to the payment for device-dependent APCs. They argued that it 
creates inequities for hospitals that have low wage indices, due to the 
application of the wage adjustment to 60 percent of the APC rate, even 
though the cost of the device is often much more than 60 percent of the 
APC payment and the device costs are the same regardless of the 
location of the facility. The commenters objected to hospitals in high 
cost areas receiving a premium for providing these service, and 
hospitals in low cost areas receiving what they viewed as a payment 
penalty for furnishing these services. The commenters asked that the 
wage index be applied only to 20 percent, rather than the current 60 
percent, of the payment for certain device-dependent APCs, specifically 
0039, 0107, 0108, 0222, 0224, 0225, 0226, 0227, 0315, 0418, 0654, 0655, 
and 0656.
    Response: The immediate effect of changing the application of the 
wage index from 60 percent to 20 percent for these APCs is likely to 
lower payments to hospitals in high cost areas, which we believe likely 
provide the higher volumes of these services, and to raise payments in 
low cost areas that likely furnish fewer services. Therefore, we 
believe that such a change would actually result in lower overall OPPS 
payment for the procedures. Moreover, any such suggested change could 
not be done in isolation. At the beginning of the OPPS, we performed a 
regression analysis resulting in a determination to wage adjust 60 
percent of the payment for each APC. This analysis examined the extent 
to which the body of costs for services furnished in the outpatient 
department was split between wage and nonwage costs. We determined that 
60 percent is an average across all service types, many of which have 
significant labor costs (for example, visits, drug administration 
services, and diagnostic tests). We reaffirmed the appropriateness of 
applying the wage

[[Page 68068]]

index to 60 percent of the APC payment during our development of the CY 
2006 OPPS (70 FR 68533). By definition, as an average across all 
services, a standard wage adjustment could not be linked to specific 
services, particularly the least expensive and most expensive services. 
To change the application of the wage index for certain device-
dependent APCs as commenters request would require reassessing the 
application of the wage index to all services. In the CY 2006 OPPS 
final rule, we committed to assessing the effects of the wage index on 
the device-dependent APCs. We are continuing our efforts in this area.
    Comment: Some commenters fully supported packaging CPT codes 93640 
(Electrophysiological evaluation of single or dual chamber pacing 
cardioverter-defibrillator leads including defibrillation threshold 
evaluation) and 93641 (Electrophysiological evaluation of single or 
dual chamber pacing cardioverter-defibrillator leads including 
defibrillation threshold evaluation; with testing of single or dual 
chamber cardioverter defibrillator) because this approach greatly 
increased the number of single bills that were available for 
calculating the median costs of APCs 0107 and 0108. Other commenters 
objected to the packaging of these CPT codes where they appeared on a 
claim unless the claim also contained a HCPCS code assigned to APCs 
0107, 0108, and 0106. Some commenters also objected to packaging 93640 
and 93641 into services assigned to APC 0418 because they believed that 
the packaged services were not performed at the time that procedures in 
APC 0418 were performed. They were concerned that packaging these 
testing codes inappropriately raised the median cost of APC 0418.
    Response: We continue to believe that the costs of CPT codes 93640 
and 93641 are appropriately packaged because they are performed only 
during the course of identifiable surgical procedures. Under the OPPS 
data development process, the cost of a packaged HCPCS code on a claim 
is added to the cost of the single major procedure code that is 
reported on the same claim, along with other packaged costs also on the 
claim. In that manner, separate payment for the procedure provides 
payment for the packaged HCPCS code as well. Because of the enormous 
number of HCPCS codes, it is not practical to include logic that 
specifies that a particular HCPCS code is packaged with specified 
services but not with others. We rely upon hospitals to correctly code 
the claims they report to Medicare because they have significant 
incentives to do so (such as, payment and audit concerns).
    After carefully considering the public comments received, we are 
finalizing our proposed payment policies for device-dependent APCs for 
CY 2007. The CY 2007 payment rates for device-dependent APCs are based 
on their median costs calculated from CY 2005 nontoken claims that 
passed the device edits, without application of a maximum payment 
reduction floor in comparison with CY 2006 payment medians. Discussions 
of HCPCS code and APC-specific issues for device-dependent APCs are 
found in section III.D of this preamble, where other APC-specific 
policies are also discussed.
BILLING CODE 4120-01-P

[[Page 68069]]

[GRAPHIC] [TIFF OMITTED] TR24NO06.018


[[Page 68070]]


[GRAPHIC] [TIFF OMITTED] TR24NO06.019

BILLING CODE 4120-01-C
3. Devices Billed in the Absence of an Appropriate Procedure Code
    As we discussed in the proposed rule (71 FR 49573), in the course 
of examining claims data for creation of the payment rates for the CY 
2007 OPPS proposed rule, we identified circumstances in which hospitals 
billed a device code but failed to also bill any procedure code with 
which the device could be used correctly. These errors in billing have 
led to the costs of the device being packaged with an incorrect 
procedure code and also have caused the hospital to be paid incorrectly 
for the service furnished if the device was appropriately reported. We 
discussed the billing of devices with incorrect procedure codes with 
the APC Panel at its March 2006 meeting, and the APC Panel recommended 
that we explore the extent to which it would be appropriate to 
establish edits for HCPCS device codes to ensure that hospitals also 
bill procedures in which the devices would be used on the same claim.

[[Page 68071]]

    As we stated in the proposed rule, we examined our CY 2005 claims 
data and found that incorrect billing occurred more often with some 
devices than with others. As noted in the CY 2007 OPPS proposed rule 
(71 FR 49573), we expected to implement device to procedure code edits 
for the specified devices and their associated procedures, that we 
believed must be reported on a claim with the specified device for the 
claim to be correctly coded and the device costs properly attributed to 
procedures with which they were used. The devices for which we expected 
to implement edits are shown below in Table 19, as well as in Table 20 
of the proposed rule (71 FR 49573 and 49574), and are posted on the CMS 
outpatient hospital Web site, along with our initial draft of all the 
procedures with which they could be appropriately used and thus 
reported. As noted in the proposed rule (71 FR 49573), we believed that 
the establishment of claims edits reflected merely standard operational 
and administrative practice. However, as the public may assist in 
establishing appropriate edits, we, therefore, asked that comments 
regarding the specific associations of device codes and procedure codes 
be provided to the following email address: [email protected]. 
This is the same email address to which comments on the existing 
procedure to device edits should be directed. Comments submitted on 
this issue to this mail box were not comments on the proposed rule and 
as stated in our proposed rule (71 FR 49573), we are not responding to 
them in this CY 2007 OPPS final rule.
    However, we are taking this opportunity to advise the public that 
we will implement these edits effective with the January 2007 OCE. The 
edits will be posted on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/, and as with the device edits currently in 
place, we will continue to accept comments on them indefinitely at the 
email address identified above.

 Table 19.--Devices Which Must Be Billed With Associated Procedure Codes
------------------------------------------------------------------------
                 Device                            Description
------------------------------------------------------------------------
C1721..................................  AICD, dual chamber.
C1722..................................  AICD, single chamber.
C1767..................................  Generator, neuro non-recharg.
C1777..................................  Lead, AICD, endo single coil.
C1778..................................  Lead, neurostimulator.
C1779..................................  Lead, pmkr, transvenous VDD.
C1785..................................  Pmkr, dual, rate-resp.
C1786..................................  Pmkr, single, rate-resp.
C1820..................................  Generator, neuro rechg bat sys.
C1882..................................  AICD, other than sing/dual.
C1895..................................  Lead, AICD, endo dual coil.
C1896..................................  Lead, AICD, non sing/dual.
C1897..................................  Lead, neurostim test kit.
C1898..................................  Lead, pmkr, other than trans.
C1899..................................  Lead, pmkr/AICD combination.
C1900..................................  Lead, coronary venous.
C2619..................................  Pmkr, dual, non rate-resp.
C2620..................................  Pmkr, single, non rate-resp.
C2621..................................  Pmkr, other than sing/dual.
------------------------------------------------------------------------

4. Payment Policy When Devices Are Replaced Without Cost or Where 
Credit for a Replaced Device Is Furnished to the Hospital
    As we discuss above in the context of the calculation of median 
costs for ICDs and pacemakers, in recent years there have been several 
field actions and recalls with regard to failure of these devices. In 
many of these cases, the manufacturers have offered replacement devices 
without cost to the hospital or credit for the device being replaced if 
the patient required a more expensive device. In some circumstances 
manufacturers have also offered, through a warranty package, to pay 
specified amounts for unreimbursed expenses to persons who had 
replacement devices implanted. In addition, we noted in the proposed 
rule that we believed that incidental device failures that are covered 
by manufacturer warranties occur routinely. While we understood that 
some device malfunctions might be inevitable as medical technology 
grows increasingly sophisticated, we believed that early recognition of 
problems would reduce the number of people with the potential to be 
adversely affected by these device problems. We indicated our belief 
that the medical community needs heightened and early awareness of 
patterns of device failures, voluntary field actions, and recalls so 
that they can take appropriate action to care for our beneficiaries. 
Systematic efforts must be undertaken by all interested and involved 
parties, including manufacturers, insurers, and the medical community, 
to ensure that device problems are recognized and addressed as early as 
possible so that people's health is protected and high quality medical 
care is provided. As indicated in the CY 2007 OPPS proposed rule (71 FR 
49574), we are taking several steps to assist in the early recognition 
and analysis of patterns of device problems to minimize the potential 
for harmful device-related effects on the health of Medicare 
beneficiaries and the public in general.
    In recent years, CMS has recognized the importance of data 
collection as a condition of Medicare coverage for selected services. 
In 2005, CMS issued a National Coverage Determination (NCD) that 
expanded coverage of ICDs and required registry participation when the 
devices were implanted for certain clinical indications. The NCD 
included this requirement in order to ensure that the care received by 
Medicare beneficiaries was reasonable and necessary and, therefore, 
appropriately reimbursed. Presently, the American College of 
Cardiology--National Cardiovascular Data Registry (ACC-NCDR) in 
partnership with the Heart Rhythm Society collects these data and 
maintains the registry.
    In addition to ensuring appropriate payment of claims, collection, 
and ongoing analysis of ICD implantation, data can speed public health 
action in the event of future device recalls. The systematic recording 
of device manufacturer and model number can enhance patient and 
provider notification. Analysis of registry data may uncover patterns 
in complication rates (for example, device malfunction, device-related 
infection, and early battery depletion) associated with particular 
devices that signify the need for a more specific investigation. 
Patterns found in registry data may identify problems earlier than the 
currently available mechanisms, which do not systematically collect 
such detailed information surrounding procedures.
    As we indicated in the proposed rule, we encouraged the medical 
community to work to develop additional registries for implantable 
devices, so that timely and comprehensive information is available 
regarding devices, recipients of those devices, and their health status 
and outcomes. While participation in an ICD registry is required as a 
condition of coverage for ICD implantation for certain clinical 
conditions, we believe that the potential benefits of registries extend 
well beyond their application in Medicare's specific national coverage 
determinations. As medical technology continues to swiftly advance, 
data collection regarding the short and long term outcomes of new 
technologies, and especially concerning implanted devices that may 
remain in the bodies of patients for their lifetimes, will be essential 
to the timely recognition of specific problems and patterns of

[[Page 68072]]

complications. This information will facilitate early interventions to 
mitigate harm and improve the quality and efficiency of health care 
services.
    Moreover, data from registries may help further the development of 
high quality, evidence-based clinical practice guidelines for the care 
of patients who may receive device-intensive procedures. In turn, 
widespread use of evidence-based guidelines may reduce variation in 
medical practice, leading to improved personal and public health. 
Registry information may also contribute to the development of more 
comprehensive and refined quality metrics that may be used to 
systematically assess and then improve the safety and quality of health 
care. Such improvements in the quality of care that result in better 
personal health will require the sustained commitment of industry, 
payers, health care providers, and others towards that goal, along with 
excellent and open communication and rapid system-wide responses in a 
comprehensive effort to protect and enhance the health of the public. 
We look forward to further discussions with the public about new 
strategies to recognize device problems early and how to definitively 
address them, in order to minimize both the harmful health effects and 
increased health care costs that may result.
    In addition, in the proposed rule we stated that we believed that 
the routine identification of Medicare claims where hospitals identify 
and then appropriately report selected services performed under the 
OPPS when devices are replaced without cost to the hospital or with 
full credit to the hospital for the cost of the replaced device, should 
provide comprehensive information regarding the outpatient hospital 
experiences of Medicare beneficiaries with certain devices that are 
being replaced. Because Medicare beneficiaries are common recipients of 
implanted devices, this claims information may be particularly helpful 
in identifying patterns of device problems early in their natural 
history so that appropriate strategies to reduce future problems may be 
developed.
    In addition to our concern for the public health, we also noted 
that we have a fiduciary responsibility to the Medicare trust fund to 
ensure that Medicare pays only for covered services. Therefore, we 
proposed, effective for services furnished on or after January 1, 2007, 
to reduce the APC payment and beneficiary copayment for selected APCs 
in cases in which an implanted device is replaced without cost to the 
hospital or with full credit for the removed device. Specifically, we 
proposed to revise the existing regulations by adding new Sec.  419.45, 
Payment and copayment reduction for replaced devices. This proposed 
regulation was intended to cover certain devices for which credit for 
the replaced device is given or which are replaced as a result of or 
pursuant to a warranty, field action, voluntary recall, involuntary 
recall, and certain devices which are provided free of charge. As 
proposed, it would provide for a reduction in the APC payment rate when 
we determine that the device is replaced without cost to the provider 
or beneficiary or when the provider receives full credit for the cost 
of a replaced device. We proposed that the amount of the reduction to 
the APC payment rate would be calculated in the same manner as the 
offset amount that would be applied if the implanted device assigned to 
the APC had pass-through status as defined under Sec.  419.66. We also 
proposed that the beneficiary's copayment amount would be calculated 
based on the reduced APC payment rate.
    We indicated that we believed that this would be appropriate 
because in these cases the full cost of the replaced device would not 
be incurred and, therefore, we believed that an adjustment to the APC 
payment would be necessary to remove the cost of the device. We also 
indicated that we believe that the averaging nature of the calculation 
of the amount of the adjustment would cause it to be appropriately 
applied to cases of credit for the replaced device, regardless of 
whether there is a residual cost due to the implantation of a more 
expensive device.
    Moreover, we stated that we also believe that the proposed 
adjustment was consistent with section 1862(a)(2) of the Act, which 
excludes from Medicare coverage an item or service for which neither 
the beneficiary nor anyone on his or her behalf has an obligation to 
pay. Payment of the full APC payment rate in these cases in which the 
device was replaced under warranty or in which there was a full credit 
for the price of the recalled or failed device effectively results in 
Medicare payment for a noncovered item. Moreover, it results in 
creation of a beneficiary liability for the copayment associated with 
the device for which the beneficiary has no liability. Therefore, we 
proposed to adjust the APC payment rate in these circumstances under 
the authority of section 1833(t)(2)(E) of the Act, which permits us to 
make equitable adjustments to the OPPS payment rates.
    As we indicated in the proposed rule, we recognized that in many 
cases, the packaged cost of the device is a relatively modest part of 
the APC payment for the procedure into which the device cost is 
packaged. In the case of devices of modest cost, we believed that the 
averaging nature of payments under the OPPS based on the conversion of 
charges to costs with CCRs would incorporate any significant savings 
from a warranty replacement, field action, or recall into the payment 
rate for the associated procedural APC and that no specific adjustment 
would be necessary or appropriate. However, in other cases, such as 
implantation of an ICD, the cost of the device is the majority of the 
cost of the APC and payment at the full payment rate for the procedural 
APC would pay the hospital much in excess of its incurred cost for the 
service.
    As we discuss above, we proposed to set the APC payment rates for 
device-dependent APCs for the CY 2007 OPPS using only claims that 
contain appropriate devices to ensure that we make appropriate full 
payment when the hospital initially incurs the full cost of the device. 
Beginning in CY 2005, we required that device codes be billed for 
devices used and specifically required that hospitals bill certain 
device codes for some services. We are using the CY 2005 claims to set 
the payment rates for the CY 2007 OPPS. Currently, where the device is 
furnished without cost to the hospital, we have authorized hospitals to 
charge less than $1.01.
    We authorized this charge because the CMS device edits require that 
the hospital must report an appropriate device if they bill for certain 
codes that cannot be performed without a device or the claim will be 
returned. Moreover, the Fiscal Intermediary Standard System will not 
accept the claim unless there is a charge for each HCPCS code billed. 
In addition, we were seeking a means of identifying these recall cases 
in the data. Therefore, by authorizing hospitals to charge less than 
$1.01 for the device we enabled the claim to be paid and also provided 
a mechanism for identifying devices for which the hospital incurred no 
expense.
    Where we set the payment rates for these device-dependent APCs 
using only claims that contain the full costs of devices when they are 
purchased by hospitals and exclude claims for which there is no 
appropriate device code or a charge for the device of less than $1.01, 
the proposed APC payments into which the full costs of the devices have 
been packaged would result in excessive program payments and 
beneficiary copayments for the services being furnished if the devices 
were provided without cost to hospitals. To avoid

[[Page 68073]]

excessive payments in these circumstances, as noted previously we 
proposed to adjust the APC payment rates when implanted devices have 
been replaced without cost to the hospital or beneficiary or where full 
credit for such a device has been given because the replacement device 
was of greater cost than the originally implanted device.
    We proposed that the adjustment would be limited to the APCs listed 
in Table 21, of the CY 2007 OPPS proposed rule (71 FR 49577) but only 
when the purpose of the procedure was to replace a device that was 
reported by a HCPCS code in Table 22 of that rule (71 FR 71 FR 49578), 
which was furnished without cost or at full credit by the manufacturer. 
We proposed that the following three criteria must each be met for an 
APC to be subject to the adjustment. We selected the APCs in Table 21 
of the proposed rule on the basis of these three criteria.
    The first criterion we proposed was that all procedures assigned to 
the selected APCs must require implantable devices that would be 
reported if device replacement procedures were performed. Therefore, 
the device being replaced must be necessary for the service to be 
furnished and without the devices, the services assigned to the APCs 
could not be performed. For services, and, therefore, their assigned 
APCs, where a device was not needed or where it might or might not be 
needed to perform a procedure, we did not believe that reducing the 
payment for the APCs would be appropriate because the charges for the 
devices were unlikely to be a significant factor in establishing the 
rates for the APCs.
    The second criterion we proposed was that the required devices must 
be surgically inserted or implanted devices that remain in the 
patient's body after the conclusion of the procedures, at least 
temporarily. We believed this was necessary to establish that the 
replacement device was a direct replacement for the device being 
removed. In cases of failures of devices that were surgically inserted 
or implanted but did not remain in the patient's body after the 
conclusion of procedures, we believe that it was highly likely that the 
replacement device was not specifically used to care for the patient on 
whom the original defective device was used and that, where a defective 
device of this type was used, there was no savings to the hospital. For 
example, if a vascular catheter failed during a procedure, we believed 
that the physician would probably use another similar catheter to 
finish the procedure. In these cases the hospital would correctly 
charge for the catheter that was used, and there would be no savings to 
the hospital from that procedure. The hospital would likely charge for 
both the defective device and the device used to complete the procedure 
because both catheters were used to provide the full service. We 
believed that if a replacement catheter was furnished to the hospital 
under warranty from the manufacturer, it would be used at a much later 
date on a different patient, it would most likely be charged to that 
patient account, and it would be unlikely to be specifically identified 
as being furnished without cost to the hospital. In these cases, we 
expected that any cost savings from the replacement devices such as 
these (for example, catheters) that are furnished without cost would be 
incorporated into the median costs for the procedures in the normal 
course of the data process through application of the CCRs generated 
from the cost reports.
    The third criterion we proposed was that the offset percent for the 
APC (that is, the median cost of the APC without device costs divided 
by the median cost of the APC with devices) must be significant. For 
this purpose, we defined a significant offset percent as exceeding 40 
percent. We believed that this percent was appropriate because our 
studies have shown that approximately 60 percent of the cost of OPPS 
services is wage-related, and that approximately 40 percent of the cost 
of OPPS services is not wage related. This is why we wage adjust 60 
percent of the APC payment rates for all APCs, including APCs for which 
a greater percentage of the APC payment is for the cost of a device.
    We believed that once the device share of an APC exceeded the 40 
percent we attribute to costs other than wage costs (for example, 
device costs, capital costs, plant costs, and supplies other than 
devices), the device cost is a significant part of the APC cost. 
Therefore, where the device costs in an APC exceed 40 percent, which is 
the average of all types of nonwage-related costs across all APCs, we 
proposed to define the device costs as ``significant'' for purposes of 
this proposed policy.
    We recognized in the proposed rule that it might be appropriate to 
define ``significant'' for this purpose at a different percentage of 
the APC cost because there are costs other than device costs (for 
example, capital costs and other supply costs) in the 40 percent of 
service costs to which the wage adjustment does not apply. We indicated 
that we would reassess for future years whether it is appropriate to 
define ``significant'' for this purpose at a level other than 40 
percent.
    For purposes of making the proposed adjustment, we proposed to 
adapt the methodology that we have employed to establish an offset for 
the device costs incorporated into APCs in cases where a pass-through 
device is also being billed. We currently calculate the offset amount 
by first calculating a median including device costs and then 
calculating a median excluding device costs using single bills that 
contain devices. We then divide the ``without device'' median by the 
``with device'' median and subtract the percent from 100 to acquire the 
percent of cost attributable to devices in the APC. We apply this 
percent to the payment rate of the APC to determine the offset amount. 
For example, this is the methodology we used to calculate the offset 
amount for APC 0222 (Implantation of Neurological Device) when current 
pass-through device C1820 (Generator, neuro rechg bat sys) is billed on 
the same claim. We indicated in the proposed rule that we believed that 
it was appropriate to apply this same methodology in circumstances when 
we needed to remove the cost of the device from the APC payment, not 
because the device was being paid under pass-through but because the 
hospital was either not incurring the cost for the replaced device or 
had been given full credit for the replaced device (71 FR 49576). In 
both cases, the intent was to remove the cost of the device from the 
APC payment rate.
    Using this methodology, we calculated the proposed offset amounts 
by first calculating an APC median cost including device costs and then 
calculating a median cost excluding device costs, using only single 
bills that met our device edits and did not have token charges for 
devices. We then divided the ``without device'' median cost by the 
``with device'' median cost and subtracted the percent from 100 to 
acquire the percent of cost attributable to devices in the APC. We next 
applied this percent to the payment rate for the APC to determine the 
offset amount.
    The following is an example of the payment reduction we proposed in 
the case of replacement of an ICD under warranty. Where the 
cardioverter defibrillator pulse generator described by HCPCS code 
C1721 (AICD, dual chamber) is replaced under warranty during a 
procedure described by HCPCS code G0298 (Insertion of dual chamber 
pacing cardioverter defibrillator pulse generator), the hospital would 
report HCPCS code G0298 with a specified modifier and would also report 
HCPCS code C1721 with a token charge for the device. Assuming the 
hospital had a wage index of 1, based upon CY 2007

[[Page 68074]]

proposed rule data the payment rate for APC 0107 after adjustment would 
be $1862.27. That is, the adjusted payment rate would equal the 
unadjusted payment rate for APC 0107 ($17,185.34) less the warranty 
reduction percentage (Table 21 of the proposed rule at 71 FR 49577) of 
89.13 percent ($15,317.29). Because the adjustment amount is set for 
the APC, the same adjustment amount would be removed if devices 
reported under HCPCS code C1722 or C1882 were reported with HCPCS code 
G0297. This would be identical to the amount of adjustment that would 
apply to the payment for a pass-through device if there were, 
hypothetically, a new ICD to which we had given pass-through status (no 
ICD currently has pass-through status) and if the reduction amount in 
Table 21 of the proposed rule were the appropriate reduction amount.
    We proposed to both adjust the APC payment to remove payment for 
the device furnished without cost to the hospital or beneficiary and 
also to decrease the beneficiary copayment in proportion to the reduced 
APC payment so that the beneficiary would, in many but not all cases, 
share in the cost savings attributable to the provision of the device 
without cost by the manufacturer. We proposed that when a device was 
replaced without cost to the hospital under warranty or recall or a 
credit was provided for the cost of a failed or recalled device (unlike 
cases of offset for a pass-through device), the beneficiary's copayment 
would be calculated based on the reduced APC payment rate, maintaining 
the same percentage copayment as would apply to the unadjusted APC 
payment if the inpatient deductible were not exceeded. We proposed this 
because we believed that it was appropriate to reduce the beneficiary 
copayment in these cases because the device was being furnished or 
credited by the manufacturer without obligation on the part of the 
beneficiary. We noted, however, that in the case of some high cost 
APCs, making the payment adjustment in a recall or warranty situation 
might not result in reduction of the copayment because the copayment, 
although based on the reduced payment rate, might continue to exceed 
the inpatient deductible and, therefore, would continue to be set at 
the inpatient deductible.
    As we discussed in the proposed rule, this contrasted with the case 
of pass-through devices, where the beneficiary was liable for the 
copayment on the full APC amount (which, in the case of high cost APCs, 
was limited to the Medicare inpatient deductible) but paid no copayment 
for the incremental cost of the pass-through device. We stated that 
this was appropriate in the case of payment for pass-through devices 
because the hospital incurred costs for both the service and the 
device, and Medicare paid for both the service through the full APC 
payment and for the incremental cost of the pass-through device above 
the costs of associated devices already reflected in the APC payment at 
charges reduced to cost by a CCR. The pass-through payment amount was 
reduced only to prevent the program from making duplicate payment for a 
portion of the device, once as part of the APC payment and once through 
the pass-through payment.
    We proposed to implement the adjustment through the use of an 
appropriate modifier specific to a device replacement without cost or 
crediting of the cost of a device by the manufacturer. We proposed that 
hospitals would be required to report the modifier appended to a 
specific procedure on claims for services when two conditions are met. 
The first condition was that the procedure was assigned to one of the 
APCs in Table 21 of the proposed rule. We have discussed above the 
criteria that we employed for selecting the APCs to which we proposed 
that this policy would apply. We proposed that the second condition 
would be that the device for which the manufacturer furnished a 
replacement device (or provided credit for the device being replaced) 
would be one of the devices included in Table 22 of the proposed rule. 
We proposed to restrict the devices to which the adjustment would apply 
to those included in Table 22 of the proposed rule in order to ensure 
that the adjustment would not be triggered by the replacement of an 
inexpensive device whose cost would not constitute a significant 
proportion of the total payment rate for an APC.
    We also proposed that the presence of the modifier would trigger 
the adjustment in payment for the APCs in Table 21 of the proposed 
rule. While we recognized that this would create a reporting burden for 
hospitals, we indicated that we believed that the reporting requirement 
would be unavoidable. Only hospitals could report whether the 
circumstances for reduced payment as described above were met and, 
therefore, we saw no option other than to have hospitals report this 
information to us. We recognized that the current FB modifier (``Item 
furnished without cost to provider, supplier or practitioner'') might 
not be appropriate in cases in which the replacement device was a more 
expensive device than the device being removed and that it might need 
to be changed to expand its use for all potential APC payment 
adjustment scenarios.
    We noted in the proposed rule that we believed that our proposed 
policy would accomplish three important goals. First and foremost, it 
would advise us of the extent to which devices are being replaced due 
to device failures so that, if patterns are identified, we could 
explore them to see if there are systemic problems with certain 
devices. We believed that the reporting of a specific modifier with 
certain procedure codes would allow us to examine patterns of delivery 
of specific hospital services when implanted devices are replaced 
without cost or with full credit for the cost of a device by the 
manufacturer, in comparison with publicly available information about 
problematic devices. We also stated that we believed that analysis of 
outpatient hospital claims would serve as an additional source of 
information to the medical community about patterns of device failures, 
voluntary field actions, and recalls, contributing to improved 
awareness and understanding of problems.
    Secondly, we explained that we believed that it would ensure 
equitable adjustment to the payments for surgical procedures to replace 
problematic devices by providing payments to hospitals only for the 
nondevice-related procedural costs when a device is replaced without 
cost to the hospital for the device or with full credit for the removed 
device. Thirdly, we noted that we believed that it would also identify 
those claims that contained reduced device charges due to the full 
credit provided by the manufacturer for a replaced device so that in 
the future we could assess the impact of these claims on median costs 
for the services into which the device costs are packaged.
    We proposed that the policy would be effective for services 
furnished on or after January 1, 2007. We believed that this proposed 
policy was necessary to enable us to secure claims data that might be 
used to identify trends in device problems that led to device 
replacements, and that it would also be necessary to fulfill our 
fiduciary responsibility to the Medicare program by not providing 
payments for items that were excluded from coverage under Medicare law 
because neither the beneficiary nor any party on his or her behalf had 
an obligation to pay.
    At its August 2006 meeting, the APC Panel recommended that CMS 
evaluate the proposed percentage adjustments in cases in which the 
device is furnished without cost or with credit for the replaced device 
to ensure that they have taken into account the administrative

[[Page 68075]]

resources required for hospitals to provide the replacement devices. In 
reviewing this recommendation, we have carefully considered the issue 
of administrative costs involved in furnishing the replacement devices 
and have concluded that the residual payment for the procedure should 
adequately compensate the provider for all administrative costs of 
furnishing the services, whether the device is furnished with or 
without cost to the provider. We elaborate on our responses to this 
recommendation in the discussion below.
    We received a number of comments on our discussion of data 
collection and the potential use of that data from a public health 
perspective. We agree with commenters that only data elements required 
to answer predefined questions should be collected. In addition to 
serving a public health role, we agree that data collection in 
registries may offer transparency once devices are on the market.
    We also agree with commenters that registry data may not be 
sufficient to develop clinical practice guidelines, and we believe that 
the process in place by many medical professional societies 
appropriately establishes guidelines based on the strength of evidence 
in which evidence from controlled clinical trials would be stronger 
than registry data.
    We received a number of public comments regarding Coverage with 
Evidence Development (CED) and registry funding that are outside the 
scope of this rule; therefore, we are not responding to them in this 
final rule with comment period.
    We received several public comments concerning our proposal for CY 
2007. A summary of the comments and our responses follow.
    Comment: Some commenters supported the proposed policy in cases in 
which the hospital incurs no cost for the device being replaced under 
warranty or otherwise without cost by the manufacturer. However, other 
commenters stated that the proposal to remove 100 percent of the cost 
of the devices is not appropriate because of the acquisition, handling, 
and administrative costs associated with the acquisition of the 
replacement device. The commenters indicated that although the hospital 
does not pay for the device, the hospital must record the special ``no 
charge'' status of the device, advise the finance and patient accounts 
departments how to charge for it, and report to Medicare that the 
procedure involves replacement of a defective device. They pointed out 
that although the device may be acquired without cost to the hospital, 
the hospital nevertheless incurs costs due to the special handling of 
the billing and accounting for the device. One commenter proposed that 
CMS reduce the APC payment by 70 to 80 percent of the offset amount 
rather than by the entire offset amount. Another commenter agreed with 
the proposed policy, provided that CMS excludes claims for these APCs 
that are reported with condition code 50 from the median cost 
calculation because including them would understate the device costs 
that should be packaged.
    Some commenters objected to the application of the policy in the 
case of upgraded devices in which the hospital is given a credit for 
the device that is covered under warranty but the hospital must pay the 
difference between the manufacturer's charge for the replaced device 
and the upgraded device being inserted and in the case of replacement 
under warranty in which there is a partial credit because the warranty 
does not cover the full replacement cost of the device. The commenters 
indicated that the same issue arises when one type of device is 
replaced with a different type of device (for example, a pacemaker 
being replaced under warranty by an ICD), whose procedural payment may 
be provided through a different APC than the procedural APC associated 
with the device being replaced. The commenters argued that these cases 
should be exempt from any reduction, notwithstanding that the hospital 
receives a credit for the device being replaced. Other commenters urged 
CMS to reduce the amount of the adjustment to the APC payment rate in 
these cases. They offered to work with CMS to develop the amount of the 
reduction that would apply in such situations.
    Response: We continue to believe that it is appropriate to reduce 
the amount of the APC payment by the full estimated percentage of 
device cost, both in cases in which the hospital receives the device 
without cost and in cases in which the hospital receives a credit 
toward an upgrade for the device that is being replaced. We are 
concerned about a payment policy that would apply a smaller APC payment 
percentage reduction in upgrade cases, because we have no way of 
estimating an appropriate offset amount based on the CY 2005 claims 
data. We are unable to identify upgrade cases in our CY 2005 claims 
data, and we will not be able to identify such claims until our CY 2007 
data are available for the CY 2009 OPPS update. In the meantime, we 
believe that our two alternatives would be either to provide the full 
APC payment or reduce the APC payment by the relevant full offset 
amount. We believe that making the full APC payment would result in 
significant overpayment because we are specifically establishing our CY 
2007 payment rates based on claims where hospitals incur device costs, 
and in most cases those claims would include the full device costs. If 
we were to take no APC payment reduction in upgrade cases, such an 
approach would favor device upgrades, rather than replacement with a 
comparable device, in warranty or recall cases where the surgical 
procedure to replace the device with an upgraded device is only 
medically necessary because of the original defective device, for which 
the manufacturer bears responsibility.
    As discussed above, we calculated the CY 2007 payment rates for the 
APCs subject to the reduction policy using only claims which contained 
appropriate devices and for which there were no token charges for the 
devices. We used this methodology to maximize the probability that we 
captured all of the costs of the devices in these APCs in all 
situations where hospitals incurred costs to provide the devices. 
Therefore, in our median cost calculations for these device-dependent 
APCs, we used both claims where the hospital bore the full cost of the 
device and those where the hospital bore a partial device cost due to a 
manufacturer credit in an upgrade situation. The amounts by which we 
will reduce the payment for these APCs are calculated using the device 
costs that are found in the very same set of claims on which we 
calculated the median costs for the device-dependent APCs. As such, we 
believe that the percentages represent the best estimate of costs 
attributable to the devices, for which in most cases the hospital 
incurs no cost or, in the case of upgraded devices or partial credits, 
a reduced cost, and those costs are packaged into the APC payments. 
Moreover, commenters told us that upgrades account for only 10 to 15 
percent of the cases where devices are replaced under warranty or 
recall. Thus, we believe it is appropriate to use the same device 
percentage for the APC payment reduction in both cases of device 
replacement without cost to the hospital and device upgrade with a 
manufacturer credit. We recognize that in some cases the estimated 
amount of device cost, and therefore the amount of the payment 
reduction, will be more or less than the hospital cost of the device in 
a specific clinical circumstance, but as averaging is inherent in a 
prospective

[[Page 68076]]

payment system, we do not believe that it is inappropriate.
    As described below in reference to the use of modifier FB in CY 
2007, once we have CY 2007 claims data we expect that we would be able 
to examine the costs of device upgrades in recall or warranty 
replacement cases to see if they are typically significantly greater 
than the costs of replacement of a device without cost to the hospital. 
However, until we have data available that permit examination of the 
differential average costs in these two situations, we intend to 
provide payment of procedures where a manufacturer credit is provided 
toward an upgraded device at the same rate we would pay if a 
replacement device were provided by the manufacturer at no cost, by 
applying the same APC payment reduction in both situations. In this 
way, we will avoid significant overpayments while we collect claims 
data for future examination to see if an alternative payment policy 
could be warranted.
    Moreover, we do not believe that it is necessary to reduce the 
amount of the adjustment for administrative costs in these cases, as we 
believe that these costs are part of the payment that remains for the 
services furnished. Administrative costs vary significantly, with more 
resource-intensive administrative actions occasionally required even 
for the simplest services at times. Hence, we believe that the 
averaging nature of the payment that remains for the hospital 
procedural services should provide fair and adequate payment for these 
routine costs.
    With regard to the comment that we should exclude claims reported 
with condition code 50 from the median cost calculation because 
including them would understate the device costs that should be 
packaged, we do not agree. Condition code 50, ``Product replacement for 
known recall of a product--Manufacturer or FDA has identified the 
product for recall and therefore replacement,'' is placed on the claim 
at a claim level, not at a line level, and thus does not provide the 
level of specificity that the FB modifier provides. We expect to use 
the presence of the FB modifier on the line with the procedure code, as 
discussed below, to determine which claims should be removed from the 
set of claims used for calculation of the median cost.
    Comment: Several commenters asked how the FB modifier would apply 
in cases of a credit for an upgrade in a warranty or recall situation. 
The commenters asked CMS to create a second modifier for use when there 
is a device upgrade or change in device type so that CMS could exclude 
those claims from the calculation of the median cost for the devices 
and more accurately apply an appropriate reduction in these cases. The 
commenters also questioned how the multiple procedure discount would 
apply when the procedure is reported with an FB modifier, signifying 
that the device was replaced or credited under warranty. Specifically, 
commenters indicated that all of the APCs for which we proposed this 
policy have status indicator ``T'' and that, therefore, their payment 
would be reduced by 50 percent if there was a higher paid service on 
the same date of service. The commenters objected to a policy that 
would first reduce the payment for the APC due to a recall and then 
also reduce the payment rate if there was a more costly procedure on 
the claim with a status indicator of ``T.''
    Response: Effective January 1, 2007, the definition of the FB 
modifier will read: ``Item Provided Without Cost to Provider, Supplier, 
or Practitioner or credit received for replaced device (Examples, but 
not limited to: Covered under warranty, replaced due to defect, free 
sample).'' Hospitals will be instructed to append the modifier to the 
HCPCS code for the procedure in which the device was inserted on claims 
when the device that was replaced under warranty, recall or field 
action is one of the devices in Table 21 below. Claims containing the 
FB modifier will not be accepted unless the modifier is on a procedure 
code with status indicator ``S,'' ``T,'' ``V'' or ``X.'' In cases in 
which the device being replaced is replaced without cost, the provider 
will report a token device charge. In cases in which the device being 
inserted is an upgrade (either of the same type of device or to a 
different type of device), the provider will report as the device 
charge the difference between its usual charge for the device being 
replaced and the credit for the replacement device. CMS will be able to 
identify whether the device was replaced without cost by the presence 
of the token charge. Where there is not a token charge for the device 
but there is an FB modifier on a HCPCS code, CMS will assume that an 
upgrade occurred. Therefore, we believe that with the change in the 
definition of the FB modifier as of January 2007, we have no need to 
establish a second modifier for device replacement situations where a 
manufacturer provides a credit toward an upgraded device.
    If the APC to which the procedure code is assigned is one of the 
APCs listed in Table 20 below, the fiscal intermediary will reduce the 
unadjusted payment rate for the procedure by an amount equal to the 
percent in Table 20 times the unadjusted payment rate. We intend to 
publish the actual adjustment amounts on the CMS website after 
publication of this final rule with comment period. If the FB modifier 
is assigned to a procedure code that is not on Table 21, then no 
adjustment will be taken. The adjustment will occur before wage 
adjustment and before the assessment to determine if a multiple 
procedure reduction applies. There may be cases where, after removal of 
the device cost, the remaining payment for the service is less than the 
payment for another procedure with a status indicator of ``T,'' and the 
multiple procedure reduction would apply. We believe this multiple 
procedure reduction continues to be appropriate even after the APC 
payment adjustment to remove payment for the device costs, because 
there would still be the expected efficiencies in performing the 
procedure if it were provided in the same operative session as another 
surgical procedure. Thus, it would be appropriate for the remaining 
procedural payment to be reduced by 50 percent, consistent with our 
well-established multiple surgical procedure reduction policy. 
Similarly, if the procedure is interrupted before administration of 
anesthesia and appended with modifier 73 or if the reduced services 
modifier 52 appears on the line with the procedure code, the 50 percent 
reduction will be taken from the adjusted payment amount as well. We 
believe that it is appropriate to treat the service subject to the APC 
payment reduction in cases of devices replaced without cost or with a 
full credit received like any other service and to apply the standard 
reduction policies.
    Comment: One commenter objected to the application of a different 
offset percentage to APC 0385 (Level I Prosthetic Urology) than for APC 
0386 (Level II Prosthetic Urology) for purposes of the adjustment when 
a device is replaced without cost or with credit for the device being 
replaced. The commenter stated that the ratio of device costs to 
overall procedure costs is basically identical for both ,and, 
therefore, the offset percent should be 60 percent for both.
    Response: We disagree. The APC 0385 device percentage is 46.86 
percent and the APC 0386 percentage is 61.16 percent. Therefore, we 
conclude that the device cost in APC 0386 is significantly higher than 
the device code in APC 385, and it would not be appropriate to assign 
the same percentage to both.
    After carefully considering the public comments received, we are 
finalizing our proposed CY 2007 policy for reduction of APC payments in 
cases of

[[Page 68077]]

device replacement without cost or when a full credit is received 
without modification. We are also making a technical change to the 
title of the regulation at new section 419.45 to better reflect our 
policy to reduce the APC payment in cases of devices replaced without 
cost or where full credit is received. The title of the proposed 
regulation does not reflect the entire policy as proposed or finalized 
as it references only devices replaced under warranty or as a result of 
recall. The revised title to section 419.45 is ``Payment and copayment 
reduction for devices replaced without cost or full credit is 
received.''

  Table 20.--Adjustments to APCs in Cases of Devices Reported Without Cost or for Which Full Credit Is Received
----------------------------------------------------------------------------------------------------------------
                                                                                                       CY 2007
                     APC                        SI                  APC group title                     offset
                                                                                                       percent
----------------------------------------------------------------------------------------------------------------
0039.........................................   S   Level I Implantation of Neurostimulator........        78.85
0040.........................................   S   Percutaneous Implantation of Neurostimulator           54.06
                                                     Electrodes, Excluding Cranial Nerve.
0061.........................................   S   Laminectomy or Incision for Implantation of            60.06
                                                     Neurostimulator Electrodes, Excludin.
0089.........................................   T   Insertion/Replacement of Permanent Pacemaker           77.11
                                                     and Electrodes.
0090.........................................   T   Insertion/Replacement of Pacemaker Pulse               74.74
                                                     Generator.
0106.........................................   T   Insertion/Replacement/Repair of Pacemaker and/         41.88
                                                     or Electrodes.
 0107........................................   T   Insertion of Cardioverter-Defibrillator........        90.44
0108.........................................   T   Insertion/Replacement/Repair of Cardioverter-          89.40
                                                     Defibrillator Leads.
 0222........................................   T   Implantation of Neurological Device............        77.65
0225.........................................   S   Implantation of Neurostimulator Electrodes,            79.04
                                                     Cranial Nerve.
 0227........................................   T   Implantation of Drug Infusion Device...........        80.27
0229.........................................   T   Transcatherter Placement of Intravascular              46.17
                                                     Shunts.
0259.........................................   T   Level VI ENT Procedures........................        84.61
0315.........................................   T   Level II Implantation of Neurostimulator.......        76.03
0385.........................................   S   Level I Prosthetic Urological Procedures.......        83.19
0386.........................................   S   Level II Prosthetic Urological Procedures......        61.16
0418.........................................   T   Insertion of Left Ventricular Pacing Elect.....        87.32
0654.........................................   T   Insertion/Replacement of a permanent dual              77.35
                                                     chamber pacemaker.
0655.........................................   T   Insertion/Replacement/Conversion of a permanent        76.59
                                                     dual chamber pacemaker.
0680.........................................   S   Insertion of Patient Activated Event Recorders.        76.40
0681.........................................   T   Knee Arthroplasty..............................        73.37
----------------------------------------------------------------------------------------------------------------


 Table 21.--Devices for Which the FB Modifier Must Be Reported With the
   Procedure Code When Furnished Without Cost or at Full Credit for a
                             Replaced Device
------------------------------------------------------------------------
                 Device                            Description
------------------------------------------------------------------------
C1721..................................  AICD, dual chamber.
C1722..................................  AICD, single chamber.
C1764..................................  Event recorder, cardiac.
C1767..................................  Generator, neurostim, imp.
C1771..................................  Rep dev, urinary, w/sling.
C1772..................................  Infusion pump, programmable.
C1776..................................  Joint device (implantable).
C1777..................................  Lead, AICD, endo single coil.
C1778..................................  Lead, neurostimulator.
C1779..................................  Lead, pmkr, transvenous VDD.
C1785..................................  Pmkr, dual, rate-resp.
C1786..................................  Pmkr, single, rate-resp.
C1813..................................  Prosthesis, penile, inflatab.
C1815..................................  Pros, urinary sph, imp.
C1820..................................  Generator, neuro rechg bat sys.
C1882..................................  AICD, other than sing/dual.
C1891..................................  Infusion pump, non-prog, perm.
C1895..................................  Lead, AICD, endo dual coil.
C1896..................................  Lead, AICD, non sing/dual.
C1897..................................  Lead, neurostim, test kit.
C1898..................................  Lead, pmkr, other than trans.
C1899..................................  Lead, pmkr/AICD combination.
C1900..................................  Lead coronary venous.
C2619..................................  Pmkr, dual, non rate-resp.
C2620..................................  Pmkr, single, non rate-resp.
C2621..................................  Pmkr, other than sing/dual.
C2622..................................  Prosthesis, penile, non-inf.
C2626..................................  Infusion pump, non-prog, temp.
C2631..................................  Rep dev, urinary, w/o sling.
L8614..................................  Cochlear device/system.
------------------------------------------------------------------------

B. Pass-Through Payments for Devices

1. Expiration of Transitional Pass-Through Payments for Certain Devices
a. Background
    Section 1833(t)(6)(B)(iii) of the Act requires that, under the 
OPPS, a category of devices be eligible for transitional pass-through 
payments for at least 2, but not more than 3, years. This period begins 
with the first date on which a transitional pass-through payment is 
made for any medical device that is described by the category. The 
device category codes became effective April 1, 2001, under the 
provisions of the BIPA. Prior to pass-through device categories, 
Medicare payments for pass-through devices under the OPPS were made on 
a brand-specific basis. All of the initial 97 category codes that were 
established as of April 1, 2001, have expired; 95 categories expired 
after CY 2002, and 2 categories expired after CY 2003. In addition, 
nine new categories have expired since their creation. We currently 
have no category codes for pass-through devices that will expire 
January 1, 2007. We created one new category effective January 1, 2006, 
for C1820 (Generator, neurostimulator (implantable), with rechargeable 
battery and charging system), which we proposed to continue to pay 
under the pass-through provision in CY 2007 under the OPPS. This 
category was created after we published modifications to our criteria 
in the CY 2006 OPPS final rule with comment period on November 10, 2005 
(70 FR 68628 through 68631), allowing CMS to refine previous pass-
through category descriptions that would have prevented us from making 
pass-through payments for a new technology that otherwise met our 
criteria. These modifications amended the original criteria and process 
for creating additional device categories for pass-through payment that 
we published on November 2, 2001 (66 FR 55850 through 55857). Under our

[[Page 68078]]

established policy, we base the expiration dates for the category codes 
on the date on which a category was first eligible for pass-through 
payment.
    In the November 1, 2002 OPPS final rule, we established a policy 
for payment of devices included in pass-through categories that are due 
to expire (67 FR 66763). For CY 2003 through CY 2006, we packaged the 
costs of the devices no longer eligible for pass-through payments into 
the costs of the procedures with which the devices were billed in the 
claims data used to set the payment rates for those years. 
Brachytherapy sources, which are now separately paid in accordance with 
section 1833(t)(2)(H) of the Act, are an exception to this established 
policy (with the exception of brachytherapy sources for prostate 
brachytherapy, which were packaged in the CY 2003 OPPS only).
b. Policy for CY 2007
    As we stated earlier, currently we have one effective device 
category for pass-through payment, C1820, which we created for pass-
through payment effective January 1, 2006. For CY 2007, we proposed to 
continue to make payment under the pass-through provisions for category 
C1820. We proposed that this category would expire from pass-through 
payment after December 31, 2007 (71 FR 49578). This would provide the 
category transitional pass-through payment status for a 2-year period, 
in accordance with the statutory requirement that no category be paid 
as a pass-through device for less than 2 years, nor more than 3 years.
    We did not receive any public comments concerning this proposal. 
Therefore, we are finalizing our proposal to expire category C1820, 
Generator, neurostimulator (implantable), with rechargeable battery and 
charging system, from pass-through payment after December 31, 2007 
without modification.
2. Provisions for Reducing Transitional Pass-Through Payments to Offset 
Costs Packaged Into APC Groups
a. Background
    In the November 30, 2001 OPPS final rule, we explained the 
methodology we used to estimate the portion of each APC payment rate 
that could reasonably be attributed to the cost of the associated 
devices that are eligible for pass-through payments (66 FR 59904). 
Beginning with the implementation of the CY 2002 OPPS quarterly update 
(April 1, 2002), we deducted from the pass-through payments for the 
identified devices an amount that reflected the portion of the APC 
payment amount that we determined was associated with the cost of the 
device, as required by section 1833(t)(6)(D)(ii) of the Act. In the 
November 1, 2002 interim final rule with comment period, we published 
the applicable offset amounts for CY 2003 (67 FR 66801).
    For the CY 2002 and CY 2003 OPPS updates, to estimate the portion 
of each APC payment rate that could reasonably be attributed to the 
cost of an associated device eligible for pass-through payment, we used 
claims data from the period used for recalibration of the APC rates. 
That is, for CY 2002 OPPS updating, we used CY 2000 claims data, and 
for CY 2003 OPPS updating, we used CY 2001 claims data. For CY 2002, we 
used median cost claims data based on specific revenue centers used for 
device-related costs because C-code cost data were not available until 
CY 2003. For CY 2003, we calculated a median cost for every APC based 
on single claims with device codes but without packaging the costs of 
associated C-codes for device categories that were billed with the APC. 
We then calculated a median cost for every APC based on single claims 
with the costs of the associated device category C-codes that were 
billed with the APC packaged into the median. Comparing the median APC 
cost without device packaging to the median APC cost, including device 
packaging, developed from the claims with device codes also reported 
enabled us to determine the percentage of the median APC cost that was 
attributable to the associated pass-through devices. By applying those 
percentages to the APC payment rates, we determined the applicable 
amount to be deducted from the pass-through payment, the ``offset'' 
amount. We created an offset list comprised of any APC for which the 
device cost was at least 1 percent of the APC's cost.
    The offset list that we published for CY 2002 through CY 2004 was a 
list of offset amounts associated with those APCs with identified 
offset amounts developed using the methodology described above. As a 
rule, we do not know in advance which procedures residing in certain 
APCs may be billed with new device categories. Therefore, an offset 
amount is applied only when a new device category is billed with a 
HCPCS procedure code that is assigned to an APC appearing on the offset 
list.
    For CY 2004, we modified our policy for applying offsets to device 
pass-through payments. Specifically, we indicated that we would apply 
an offset to a new device category only when we could determine that an 
APC contains costs associated with the device. We continued our 
existing methodology for determining the offset amount, described 
earlier. We were able to use this methodology to establish the device 
offset amounts for CY 2004 because providers reported device codes 
(generally C-codes) on the CY 2002 claims used for the CY 2004 OPPS 
update. For the CY 2005 update to the OPPS, our data consisted of CY 
2003 claims that did not contain device codes and, therefore, for CY 
2005, we utilized the device percentages as developed for CY 2004. In 
the CY 2004 OPPS update, we reviewed the device categories eligible for 
continuing pass-through payment in CY 2004 to determine whether the 
costs associated with the device categories were packaged into the 
existing APCs. Based on our review of the data for the device 
categories existing in CY 2004, we determined that there were no close 
or identifiable costs associated with the devices relating to the 
respective APCs that were normally billed with them. Therefore, for 
those device categories, we set the offset amount to $0 for CY 2004. We 
continued this policy of setting the offset amount to $0 for the device 
categories that continued to receive pass-through payment in CY 2005.
    For the CY 2006 OPPS update, CY 2004 hospital claims were available 
for analysis. Hospitals billed device C-codes in CY 2004 on a voluntary 
basis. We reviewed our CY 2004 data and found that the numbers of 
claims for services in many of the APCs for which we calculated device 
percentages using CY 2004 data were quite small. We also found that 
many of these APCs already had relatively few single claims available 
for median calculations compared with the total bill frequencies 
because of our inability to use many multiple bills in establishing 
median costs for all APCs. In addition, we found that our claims 
demonstrated that relatively few hospitals specifically coded for 
devices utilized in CY 2004. Thus, we were not confident that CY 2004 
claims reporting device HCPCS codes represented the typical costs of 
all hospitals providing the services. Therefore, we did not use CY 2004 
claims with device codes to calculate CY 2006 device offset amounts. In 
addition, we did not use the CY 2005 methodology, for which we utilized 
the device percentages as developed for CY 2004. Two years had passed 
since we developed the device offsets for CY 2004, and the device 
offsets originally calculated from CY 2002 hospitals' claims data may 
either have overestimated or underestimated the

[[Page 68079]]

contributions of device costs to total procedural costs in the 
outpatient hospital environment of CY 2006. In addition, a number of 
the APCs on the CY 2004 and CY 2005 device offset percentage lists were 
either no longer in existence or were so significantly reconfigured 
that the past device offsets likely did not apply.
    For CY 2006, we reviewed the single new device category established 
thus far, C1820, to determine whether device costs associated with the 
new category were packaged into the existing APC structure based on 
partial CY 2005 claims data. Under our established policy, if we 
determine that the device costs associated with the new category are 
closely identifiable to device costs packaged into existing APCs, we 
set the offset amount for the new category to an amount greater than 
$0. Our review of the service indicated that the median cost for the 
applicable APC 0222 contained costs for neurostimulators that were 
similar to neurostimulators described by the new device category C1820. 
Therefore, we determined that a device offset would be appropriate. We 
announced an offset amount for that category in Program Transmittal No. 
804, dated January 3, 2006.
    For CY 2006, we are using available partial year CY 2005 hospital 
claims data to calculate device percentages and potential offsets for 
CY 2006 applications for new device categories. Effective January 1, 
2005, we require hospitals to report device HCPCS codes and their 
charges when hospitals bill for services that utilize devices described 
by the existing device codes. In addition, during CY 2005, we 
implemented device edits for many services that require devices and for 
which appropriate device HCPCS codes exist. Therefore, we expected that 
the number of claims that included device codes and their respective 
costs to be much more robust and representative for CY 2005 than for CY 
2004. We believe that use of the most current claims data to establish 
offset amounts when they are needed to ensure appropriate payment is 
consistent with our stated policy; therefore, we proposed to continue 
to do so for the CY 2007 OPPS. Specifically, if we create a new device 
category for payment in CY 2007, to calculate potential offsets we 
proposed to examine the most current available claims data, including 
device costs, to determine whether device costs associated with the new 
category are already packaged into the existing APC structure, as 
indicated earlier. If we conclude that some related device costs are 
packaged into existing APCs, we proposed to use the methodology 
described earlier and first used for the CY 2003 OPPS to determine an 
appropriate device offset percentage for those APCs with which the new 
category would be reported.
    We did not publish a list of APCs with device percentages as a 
transitional policy for CY 2006 because of the previously discussed 
limitations of the CY 2004 OPPS data with respect to device costs 
associated with procedures. We stated in the CY 2006 final rule with 
comment period (70 FR 68628) that we expected to reexamine our previous 
methodology for calculating the device percentages and offset amounts 
for the CY 2007 OPPS update, which would be based on CY 2005 hospital 
claims data where device HCPCS code reporting was required.
b. Policies for CY 2007
    For CY 2007, we proposed to continue to review each new device 
category on a case-by-case basis as we have done in CY 2004, CY 2005, 
and CY 2006, to determine whether device costs associated with the new 
category are packaged into the existing APC structure. If we determine 
that, for any new device category, no device costs associated with the 
new category are packaged into existing APCs, we proposed to continue 
our current policy of setting the offset amount for the new category to 
$0 for CY 2007. There is currently one new device category that will 
continue for pass-through payment in CY 2007. This category, described 
by HCPCS code C1820, currently has an offset amount of $8,647.81, which 
is applied to APC 0222. We proposed to update this offset for CY 2007 
based on the full year of claims data for CY 2005, the claims data year 
for our CY 2007 OPPS update. Based on full year CY 2005 claims data 
used for this final rule with comment period, the offset amount for 
C1820 is 77.65 percent of the final CY 2007 payment rate for APC 0222. 
(See Addendum A of this CY 2007 OPPS final rule with comment period for 
a listing of the final CY 2007 APC payment rates.)
    We proposed to continue our existing policy of establishing new 
categories in any quarter when we determine that the criteria for 
granting pass-through status for a device category are met. If we 
create a new device category and determine that our CY 2005 claims data 
contain a sufficient number of claims with identifiable costs 
associated with the new category of devices in any APC, we proposed to 
reduce the transitional pass-through payment for the device by the 
related procedural APC offset amount if the offset amount is greater 
than $0. If we determine that a device offset greater than $0 is 
appropriate for any new category that we create, we proposed to 
announce the offset amount in the program transmittal that announces 
the new category.
    In summary, for CY 2007, we proposed to use CY 2005 hospital claims 
data to calculate device percentages and potential offsets for CY 2007 
applications for new device categories. We proposed to publish, through 
quarterly program transmittals, any new or updated offsets that we 
calculate for CY 2007, corresponding to newly created categories or 
existing categories, respectively.
    After the CY 2007 proposed OPPS rule was published and prior to the 
publication of this final rule with comment period, we determined that 
we would establish two new device categories for transitional pass-
through payment. Therefore, we are announcing our offset policy for 
these two device categories, whose coding and payment information is 
found in Addenda A and B. We have established device categories L8690 
(Auditory osseointegrated device, external sound processor, 
replacement) and C1821 (Interspinous process distraction device 
(implantable)) for pass-through payment, effective January 1, 2007. As 
stated earlier, beginning in CY 2004 and now continuing through CY 
2007, we apply an offset to a new device category only when we 
determine that an APC contains costs associated with a related device. 
We have determined that we cannot identify device-related costs in the 
procedural APCs we expect will be billed with either of the new 
categories L8690 or C1821, that is, in APC 0256 or APC 0050, 
respectively. Therefore, we are setting the offset amount to $0 for 
device categories L8690 and C1821 for CY 2007.
    We did not receive any public comments concerning our CY 2007 
proposals for calculating device percentages and potential offset 
amounts. Therefore, we are finalizing our proposals without 
modification, and specifically applying them to device categories 
C1820, L8690, and C1821, as discussed above.

V. OPPS Payment Changes for Drugs, Biologicals, and 
Radiopharmaceuticals

A Transitional Pass-Through Payment for Additional Costs of Drugs and 
Biologicals

1. Background
    Section 1833(t)(6) of the Act provides for temporary additional 
payments or ``transitional pass-through payments'' for certain drugs 
and biological agents. As originally enacted by the Medicare,

[[Page 68080]]

Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999 
(Pub.L. 106-113), this provision requires the Secretary to make 
additional payments to hospitals for current orphan drugs, as 
designated under section 526 of the Federal Food, Drug, and Cosmetic 
Act (Pub. L. 107-186); current drugs and biological agents and 
brachytherapy sources used for the treatment of cancer; and current 
radiopharmaceutical drugs and biological products. For those drugs and 
biological agents referred to as ``current,'' the transitional pass-
through payment began on the first date the hospital OPPS was 
implemented (before enactment of the Medicare, Medicaid, and SCHIP 
Benefits Improvement and Protection Act BIPA of 2000 (Pub. L. 106-554), 
on December 21, 2000).
    Transitional pass-through payments are also required for certain 
``new'' drugs and biological agents that were not being paid for as a 
hospital outpatient department service as of December 31, 1996, and 
whose cost is ``not insignificant'' in relation to the OPPS payments 
for the procedures or services associated with the new drug or 
biological. Under the statute, transitional pass-through payments can 
be made for at least 2 years but not more than 3 years. Proposed pass-
through drugs and biologicals are assigned status indicator ``G'' in 
Addenda A and B of the CY 2007 OPPS proposed rule. The pass-through 
application and review process is explained on the CMS Web site at 
http://www.cms.hhs.gov.
    Section 1833(t)(6)(D)(i) of the Act sets the payment rate for pass-
through eligible drugs (assuming that no pro rata reduction in pass-
through payment is necessary) as the amount determined under section 
1842(o) of the Act. This payment methodology is set forth in Sec.  
419.64 of the regulations. Section 1847A of the Act, as added by 
section 303(c) of Pub. L. 108-173, establishes the use of the average 
sales price (ASP) methodology as the basis for payment for drugs and 
biologicals described in section 1842(o)(1)(C) of the Act that are 
furnished on or after January 1, 2005. The ASP methodology uses several 
sources of data as a basis for payment, including ASP, wholesale 
acquisition cost (WAC), and average wholesale price (AWP). In this 
final rule with comment period, the terms ``ASP methodology'' and 
``ASP-based'' are inclusive of all data sources and methodologies 
described therein. Additional information on the ASP methodology can be 
found at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage.
    Section 1833(t)(6)(D)(i) of the Act also states that if a drug or 
biological is covered under a competitive acquisition contract under 
section 1847B of the Act, the payment rate is equal to the average 
price for the drug or biological for all competitive acquisition areas 
and the year established as calculated and adjusted by the Secretary. 
Section 1847B of the Act, as added by section 303(d) of Pub. L. 108-
173, establishes the payment methodology for Medicare Part B drugs and 
biologicals under the competitive acquisition program (CAP). The Part B 
drug CAP was implemented July 1, 2006, and includes approximately 180 
of the most common Part B drugs provided in the physician office 
setting. The list of drugs and biologicals covered under the Part B 
drug CAP, their associated payment rates and the Part B drug CAP 
pricing methodology can be found at http://www.cms.hhs.gov/CompetitiveAcquisforBios.
    For CY 2007, we proposed to pay for drugs and biologicals that are 
granted pass-through status under the OPPS and that are included in the 
Part B drug CAP at a payment rate equal to the rate these drugs would 
be paid under the Part B drug CAP. We had several comments about this 
proposal.
    Comment: Commenters expressed concern that Part B drug CAP rates 
are insufficient to cover the costs hospitals incur for drugs, as the 
CAP rate is an average of eligible approved CAP vendor bids, and 
hospitals are not able to obtain drugs at the CAP rates because they 
are statutorily excluded from the CAP program. The commenters suggested 
that the rate for all pass-through drugs should, therefore, be set to 
the ASP methodology, regardless of the drug's inclusion in the Part B 
drug CAP.
    Response: As discussed above, our proposed methodology for setting 
payment rates for pass-through drugs that are also a part of the Part B 
drug CAP program is mandated by section 1833(t)(6)(D)(i) of the Act. In 
addition, we note that, for the two pass-through drugs that we proposed 
to pay at the Part B drug CAP rate in CY 2007, the Part B drug CAP rate 
exceeds the rate resulting from the October update of the ASP 
methodology for both drugs. Therefore, we disagree that the Part B drug 
CAP rate undermines hospitals' ability to procure drugs that are paid 
at this rate while on pass-through.
    Comment: Commenters requested that CMS clarify the amount that we 
would pay for pass-through drugs and biologicals that are also included 
as part of the Part B drug CAP. Specifically, the commenters asked for 
clarification of how CMS determines the Part B drug CAP rate.
    Response: As discussed above, the statutory language requires that 
if a drug or biological is covered under a competitive acquisition 
contract under section 1847B of the Act, the OPPS pass-through payment 
rate is equal to the average price for the drug or biological for all 
competitive acquisition areas and the year established as calculated 
and adjusted by the Secretary. As of the time of this final rule with 
comment period, the Part B drug CAP includes one national competitive 
acquisition area and one national vendor. Therefore, the average 
payment across all competitive acquisition areas at this time is also 
equal to the rate paid to the national vendor. We refer the public to 
the CY 2006 MPFS final rule (70 FR 70236) for a full description of the 
Part B CAP.
    Comment: Commenters stated that pass-through payments were required 
by law to be paid on a drug-by-drug basis, and therefore a payment 
based on the Part B drug CAP process that incorporates many drugs 
across several vendors would violate this drug-specific requirement.
    Response: We disagree that these statutory requirements pose a 
conflict. The Part B drug CAP program payment determination is 
performed on a drug-by-drug basis and complements the provisions of the 
pass-through concept. (For more information on the Part B drug CAP 
payment rate methodology, see section II.C.3. of the Interim Rule 
entitled ``Competitive Acquisition of Outpatient Drugs and Biologicals 
Under Part B'' which was published at the Federal Register on July 6, 
2005 (70 FR 39069) and section II.H.6. of the final rule entitled 
``Revisions to Payment Policies Under the Physician Fee Schedule for 
Calendar Year 2006 and Certain Provisions Related to the Competitive 
Acquisition Program of Outpatient Drugs and Biologicals Under Part B'' 
which was published in the Federal Register on November 21, 2005 (70 FR 
70236).)
    For the reasons set forth in the section above, we are finalizing 
our proposed policy to pay for drugs and biologicals with pass-through 
status in CY 2007 that are also covered under the Part B drug CAP at 
the rate each drug would be paid under the Part B drug CAP.
2. Drugs and Biologicals With Expiring Pass-Through Status in CY 2006
    Section 1833(t)(6)(C)(i) of the Act specifies that the duration of 
transitional pass-through payments for drugs and biologicals must be no 
less than 2 years and no longer than 3 years.

[[Page 68081]]

In Table 23 of the CY 2007 OPPS proposed rule (71 FR 49580), we 
proposed to allow the expiration of the pass-through status for 12 
drugs and biologicals on December 31, 2006. We also proposed to delete 
temporary CY 2006 C-codes if an alternate permanent HCPCS code was 
available for purposes of OPPS billing and payment in CY 2007.
    There are seven pass-through drugs, identified with an asterisk (*) 
in Table22 below, that are paid under the OPPS for CY 2006 at the rate 
established by the Part B drug CAP. In CY 2007, these drugs, in 
accordance with OPPS policy for all non-pass through drugs, 
biologicals, and radiopharmaceuticals, are subject to the established 
OPPS payment methodologies discussed in section V.B of this final rule 
with comment period.
    Based on our review of the existing permanent HCPCS codes available 
at the time of the CY 2007 OPPS proposed rule, we determined that HCPCS 
code J7344 (Nonmetabolic active tissue) appropriately described the 
product reported under HCPCS code C9221 in the CY 2006 OPPS. We 
proposed to delete HCPCS code C9221 and instruct hospitals to use HCPCS 
code J7344 for services furnished on or after January 1, 2007. We did 
not receive any comments on this proposal. Therefore, we are finalizing 
our proposal without modification.
    Since the publication of the proposed rule, we have determined that 
HCPCS code J7319 (Sodium hyaluronate injection) appropriately describes 
the product reported under HCPCS code C9220, and that HCPCS code J7346 
(Injectable human tissue) appropriately describes the product reported 
under HCPCS code C9222 as shown in Table 23 of the CY 2007 OPPS 
proposed rule. Therefore, in accordance with the policy described 
above, we are deleting HCPCS codes C9220 and C9222, and instructing 
hospitals to use HCPCS codes J7319 and J7346, respectively, for 
services furnished on or after January 1, 2007.
    We did not receive any public comments concerning our proposed 
policy for CY 2007. Therefore, we are finalizing our proposal to 
discontinue pass-through status as of December 31, 2006, for the 12 
drugs and biologicals shown in Table 22 below. In addition, Table 22 
indicates the final CY 2007 coding changes for these drugs and 
biologicals.

 Table 22.--List of Drugs and Biologicals for Which Pass-Through Status
                        Expires December 31, 2006
------------------------------------------------------------------------
                                 CY 2006      CY 2007     CY 2007 short
        CY 2007  HCPCS            HCPCS         APC         descriptor
------------------------------------------------------------------------
J7319........................        C9220         0896  Sodium
                                                          hyaluronate
                                                          injection
J7344........................        C9221         9156  Nonmetabolic
                                                          active tissue
J7346........................        C9222         9222  Injectable
                                                          human tissue
J0128*.......................  ...........         9216  Abarelix
                                                          injection
J0878*.......................  ...........         9124  Daptomycin
                                                          injection
J2357*.......................  ...........         9300  Omalizumab
                                                          injection
J2783........................  ...........         0738  Rasburicase
J2794*.......................  ...........         9125  Risperidone,
                                                          long acting
J7518........................  ...........         9219  Mycophenolic
                                                          acid
J9035*.......................  ...........         9214  Bevacizumab
                                                          injection
J9055*.......................  ...........         9215  Cetuximab
                                                          injection
J9305*.......................  ...........         9213  Pemetrexed
                                                          injection
------------------------------------------------------------------------
* Indicates that the drug was paid at a rate determined by the Part B
  drug CAP methodology while identified as pass-through under the OPPS.

3. Drugs and Biologicals With Pass-Through Status in CY 2007
    In the CY 2007 OPPS proposed rule, we proposed to continue pass-
through status in CY 2007 for the nine drugs and biologicals listed in 
Table 24 (71 FR 49582) that had received pass-through status as of 
April 1, 2006. We also assigned these APCs and HCPCS codes status 
indicator ``G'' in Addenda A and B of the CY 2007 proposed rule.
    We proposed to pay for drugs and biologicals that are not included 
in the Part B drug CAP at a rate equal to the payment these drugs and 
biologicals would receive in the physician office setting in CY 2007, 
where payment will be determined by the methodology described in Sec.  
414.904 and generally be equal to ASP+6 percent.
    We received several comments on our proposal to pay for pass-
through drugs and biologicals that are not included in the Part B drug 
CAP at the rate these drugs would receive in the physician office 
setting.
    Comment: Many commenters supported our proposal to provide payment 
in CY 2007 for drugs and biologicals with pass-through status at the 
rate these drugs and biologicals would receive in the physician office 
setting. However, one commenter stated that the purpose of pass-through 
payments is to recognize additional costs that hospitals incur when 
providing new and expensive drugs and biologicals that are not yet 
reflected in the OPPS APC payment rates. Therefore, the commenter 
added, pass-through drugs and biologicals should be subject to a 
methodology that provides an additional payment, above the payment 
methodology provided to non-pass through drugs and biologicals.
    Response: We appreciate the commenters' support for our proposed 
policy. In addition, we agree that the purpose of pass-through payments 
is to recognize and support hospitals that provide innovative and 
expensive therapies before these costs are reflected in the OPPS APC 
payment amounts. However, drugs are paid through their own drug 
specific APCs, typically at a rate that is based on the ASP methodology 
that reflects recent market prices. Payment rates for separately 
payable drugs are updated quarterly and do not rely on the most recent 
set of OPPS hospital claims data that results in the 2-year difference 
between hospital claims and OPPS payment rates experienced by other 
APCs. Therefore, we do not believe that pass-through drugs require a 
separate methodology or payments above the methodology used to set 
payment rates for other drugs.
    As discussed in section V.A.1. of this preamble, pass-through 
payments for CY 2007 are made under the OPPS for drugs and biologicals 
that are also included in the Part B drug CAP at the rate established 
by the Part B drug CAP. At the time of the proposed rule, two drugs 
(HCPCS codes J2503 (Pegaptanib sodium injection) and J9264 (Paclitaxel 
protein bound)) were approved for pass-through payments in CY 2007 that 
were also covered under the Part B drug CAP.

[[Page 68082]]

As we have established above, payment for these drugs will be amounts 
determined under the Part B drug CAP, which will be at a rate slightly 
different than the rate determined under the ASP methodology. Pass-
through rates for all other CY 2007 pass-through drugs will be at a 
rate equal to the rate paid in the physician office setting, as 
determined by the ASP methodology. This information is updated 
quarterly as part of the ASP methodology process, and OPPS payment 
rates are adjusted accordingly. Additional information on this ASP 
methodology is available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.
    Currently, there are no radiopharmaceuticals that would have pass-
through status in CY 2007. In the event that a new radiopharmaceutical 
agent receives pass-through status in CY 2007, we proposed to base its 
payment on the WAC for the product as ASP data for radiopharmaceuticals 
are not available. In addition, we proposed to calculate payment for 
the radiopharmaceutical at 95 percent of its most recent AWP if WAC 
information was also not available. We proposed to adopt this interim 
payment methodology in order to be consistent with how we pay for new 
drugs, biologicals, and radiopharmaceuticals without HCPCS codes, as 
discussed in the CY 2006 OPPS final rule with comment period (70 FR 
68669). We received several comments on this proposal.
    Comment: Several commenters requested that CMS pay separately for 
all radiopharmaceuticals at hospital charges reduced to cost using the 
hospital specific overall CCR.
    Response: Comments received relating to nonpass-through 
radiopharmaceuticals are addressed in section V.B.3. of this preamble, 
and comments received regarding our proposed payment methodology for 
nonpass-through drugs, biologicals and radiopharmaceuticals without 
claims data are discussed in section V.B.3.b. of this preamble.
    Our CY 2007 proposal to pay for pass-through radiopharmaceuticals 
at WAC was closely aligned with our proposal to pay for separately 
payable nonpass-through radiopharmaceuticals based on mean unit costs 
calculated from CY 2005 hospital claims data. As we discuss in section 
V.B.3. of this preamble, after careful consideration of all comments 
received, we are not finalizing this proposal for separately payable 
nonpass-through radiopharmaceuticals. Therefore, we are also not 
finalizing our proposal to use a prospective WAC-based payment 
methodology for pass-through radiopharmaceuticals in CY 2007. We 
believe it is appropriate to align our payment methodologies, whenever 
possible, within the OPPS. Therefore, for CY 2007, we are finalizing 
our payment policy for pass-through radiopharmaceuticals as follows: 
For CY 2007, hospitals will receive payment for radiopharmaceuticals 
that are granted pass-through status in CY 2007 at the hospital's 
charge for the radiopharmaceutical adjusted to the cost, using the 
hospital's overall CCR. This methodology will provide payment for 
radiopharmaceuticals granted pass-through status in CY 2007 based on 
the same payment methodology that will be used to provide payment for 
separately payable nonpass-through radiopharmaceuticals in CY 2007 in 
the OPPS.
    We discuss in section V.B.3.b. of this final rule with comment 
period that we are making separate payment in CY 2007 for new drugs and 
biologicals with a HCPCS code, consistent with the provisions of 
section 1842(o) of the Act, at a rate that is equivalent to the payment 
they would receive in a physician office setting (or under section 
1847B of the Act, if the drug or biological is covered under a 
competitive acquisition contract), whether or not we have received a 
pass-through application for the item. Accordingly, in CY 2007 the 
pass-through payment amount would equal zero for those new drugs and 
biologicals that we determine have pass-through status. That is, when 
we subtract the amount to be paid for pass-through drugs and 
biologicals under section 1842(o) of the Act (or section 1847B of the 
Act, if the drug or biological is covered under a competitive 
acquisition contract), from the portion of the otherwise applicable fee 
schedule amount or the APC payment rate associated with the drug or 
biological that would be the amount paid for drugs and biologicals 
under section 1842(o) of the Act (or section 1847B of the Act, if the 
drug or biological is covered under a competitive acquisition 
contract), the resulting difference is equal to zero.
    In the proposed rule, we used payment rates based on the ASP data 
from the fourth quarter of CY 2005 for budget neutrality estimates, 
impact analyses, and completion of Addenda A and B of the proposed rule 
because these were the most recent data available to us during the 
development of the proposed rule. We proposed to update this data with 
the most recent data available for purposes of the final rule with 
comment period. We received no comments on this proposal. Therefore, we 
have updated the payment rates for budget neutrality estimates, impact 
analyses, and completion of Addenda A and B of this final rule with 
comment period to reflect payment rates based on ASP data effective 
October 1, 2006, as this is the most recent data available at the time 
of this final rule with comment period.
    In addition, to be consistent with the ASP-based payments that 
would be made when these drugs and biologicals are furnished in 
physician offices, we proposed to make any appropriate adjustments to 
the amounts shown in Addenda A and B on a quarterly basis on the CMS 
Web site during CY 2007 if later quarter ASP methodology calculations 
indicate that adjustments to the payment rates for these pass-through 
drugs and biologicals are necessary, or in the event that they become 
covered under the competitive acquisition program. The payment rate for 
a radiopharmaceutical with pass-through status would also be adjusted 
accordingly.
    In Table 24 of the proposed rule, we listed the drugs and 
biologicals for which we proposed that pass-through status continue in 
CY 2007 (71 FR 49581). We assigned pass-through status to these drugs 
and biologicals as of April 1, 2006 and identified them in Addenda A 
and B of the proposed rule with status indicator ``G.''
    Comment: One commenter supported our pass-through determination for 
C9228 (Injection, tigecycline), and one commenter supported our pass-
through determination for Q4079 (Natalizumab injection) for CY 2007.
    Response: We appreciate the commenters' support of our pass-through 
decisions for these drugs.
    Since the time of the proposed rule, we have granted pass-through 
status in CY 2007 to an additional nine drugs and biologicals. In 
addition, in accordance with the established policy discussed above, we 
are deleting six temporary CY 2006 C-codes because we have identified 
an alternate permanent HCPCS code that is available for purposes of 
OPPS billing and payment in CY 2007. These temporary codes, and their 
permanent HCPCS replacement codes, are listed in Table 23 along with 
all drugs and biologicals that we are finalizing for pass-through 
payments in CY 2007 under the OPPS. In addition, we have identified 
with an asterisk (*) those pass-through drugs for CY 2007 OPPS that are 
also included in the Part B drug CAP.

[[Page 68083]]



                  Table 23.--List of Drugs and Biologicals With Pass-Through Status in CY 2007
----------------------------------------------------------------------------------------------------------------
                              CY 2007 proposed rule
    CY 2007  final  HCPCS             HCPCS            APC                     Short descriptor
----------------------------------------------------------------------------------------------------------------
C9232.......................                    **      9232  Injection, idursulfase.
C9233.......................                    **      9233  Injection, ranibizumab.
C9350.......................                    **      9350  Porous collagen tube per cm.
C9351.......................                    **      9351  Acellular derm tissue percm2.
J0129.......................                      C9230*9230  Abatacept injection.
J0348.......................                    **      0760  Anadulafungin injection.
J0894.......................                      C9231*9231  Decitabine injection.
J1740.......................                      C9229*9229  Injection ibandronate sodium.
J2248.......................                      C9227 9227  Micafungin sodium injection.
J2278.......................                 J2278      1694  Ziconotide injection.
J2503*......................                 J2503      1697  Pegaptanib sodium injection.
J3243.......................                      C9228 9228  Tigecycline injection.
J3473.......................                    **      0806  Hyaluronidase recombinant.
J7311.......................                      C9225 9225  Fluocinolone acetonide implt.
J8501.......................                 J8501      0868  Oral aprepitant.
J9027.......................                 J9027      1710  Clofarabine injection.
J9264*......................                 J9264      1712  Paclitaxel protein bound.
Q4079.......................                 Q4079      9126  Natalizumab injection.
----------------------------------------------------------------------------------------------------------------
* Indicates that the drug is included in the Part B drug CAP and will be paid at this methodology in 2007.
** Pass-through status was granted after publication of the CY 2007 OPPS proposed rule.

B. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without 
Pass-Through Status

1. Background
    Under the CY 2006 OPPS, we currently pay for drugs, biologicals, 
and radiopharmaceuticals that do not have pass-through status in one of 
two ways: packaged payment within the payment for the associated 
service or separate payment (individual APCs). We explained in the 
April 7, 2000 OPPS final rule with comment period (65 FR 18450) that we 
generally package the cost of drugs and radiopharmaceuticals into the 
APC payment rate for the procedure or treatment with which the products 
are usually furnished. Hospitals do not receive separate payment from 
Medicare for packaged items and supplies, and hospitals may not bill 
beneficiaries separately for any packaged items and supplies whose 
costs are recognized and paid within the national OPPS payment rate for 
the associated procedure or service. (Program Memorandum Transmittal A-
01-133, issued on November 20, 2001, explains in greater detail the 
rules regarding separate payment for packaged services.)
    Packaging costs into a single aggregate payment for a service, 
procedure, or episode of care is a fundamental principle that 
distinguishes a prospective payment system from a fee schedule. In 
general, packaging the costs of items and services into the payment for 
the primary procedure or service with which they are associated 
encourages hospital efficiencies and also enables hospitals to manage 
their resources with maximum flexibility. Notwithstanding our 
commitment to package as many costs as possible, we are aware that 
packaging payments for certain drugs, biologicals, and 
radiopharmaceuticals, especially those that are particularly expensive 
or rarely used, might result in insufficient payments to hospitals, 
which could adversely affect beneficiary access to medically necessary 
services.
    Section 1833(t)(16)(B) of the Act, as added by section 621(a)(2) of 
Pub. L. 108-173, set the threshold for establishing separate APCs for 
drugs and biologicals at $50 per administration for CYs 2005 and 2006. 
Therefore, for CY 2006, we paid separately for drugs, biologicals, and 
radiopharmaceuticals whose per day cost exceeds $50 and packaging the 
costs of drugs, biologicals, and radiopharmaceuticals whose per day 
cost is less than $50 into the procedures with which they are billed. 
In addition, we extended an exception to this packaging policy for oral 
and injectable 5HT3 forms of anti-emetic treatments (70 FR 68635 
through 68638) for CY 2006.
    At the August 2006 APC Panel meeting, the Panel recommended that 
CMS allow providers to use all available HCPCS codes for reporting 
drugs in the OPPS to reduce the administrative burden associated with 
reporting drugs using only HCPCS codes with the lowest increments in 
their code descriptors. We include our response to this recommendation 
in the discussion below.
    Comment: Several commenters recommended that CMS allow all drug, 
biological, and radiopharmaceutical HCPCS codes to be recognized under 
the OPPS, as opposed to our current policy that does not recognize some 
codes because they are not the lowest dosage unit HCPCS code available 
for an item.
    Response: We appreciate these comments, as well as the efforts of 
the commenters to identify specific drugs where the OPPS currently 
recognizes only one of several HCPS codes. As is our longstanding 
interest, we are considerate of situations where hospitals may 
experience an administrative burden that could possibly be reduced with 
a change in OPPS policy. In general, the current practice of the HCPCS 
National Panel is to establish only one HCPCS code for a particular 
drug with a single appropriate dose descriptor for reporting all doses, 
whereas historically more than one HCPCS code may have been created 
with different dose descriptors for the same drug. Typically, under the 
OPPS, we have only recognized a single HCPCS code with the lowest dose 
descriptor, as this approach assists us in data collection for OPPS 
ratesetting purposes and allows hospitals to accurately reflect all 
doses administered by billing a variety of units in relation to the 
drug's dose descriptor.
    Our current practice is to make a packaging determination based on 
historical hospital claims data for each drug, biological, and 
radiopharmaceutical HCPCS code that we recognize under the OPPS. 
Therefore, we generally determine the packaging status for the lowest 
dose descriptor that exists for a particular

[[Page 68084]]

drug, as other doses are typically assigned status indictor ``B'' (Not 
recognized under OPPS; alternate code may be available). If we were to 
recognize all the HCPCS codes that may exist for a single drug, we 
would need to consider the ramifications of such a substantial change 
on our ratesetting methodology. For example, we would need to consider 
whether to adjust our methodology to provide packaging decisions based 
upon a particular drug, rather than making a determination for each 
HCPCS code. If we did not adjust our methodology, we could have 
variable packaging determinations for multiple HCPCS codes that 
described the same drug, and it is not clear whether this would be 
appropriate. Therefore, we are not accepting the recommendation of the 
APC Panel and the commenters to recognize all available HCPCS codes in 
the CY 2007 OPPS. However, we will further explore the issues 
surrounding such an approach for the future, to further develop our 
understanding of the implications of such a change. We continue to 
believe that the current HCPCS codes recognized under the OPPS allow 
hospitals to accurately report all doses of the drugs, biologicals, and 
radiopharmaceuticals they administer.
2. Criteria for Packaging Payment for Drugs, Biologicals, and 
Radiopharmaceuticals
    As indicated above, in accordance with section 1833(t)(16)(B) of 
the Act, the threshold for establishing separate APCs for drugs and 
biologicals was set to $50 per administration during CYs 2005 and 2006. 
As this provision expires at the end of CY 2006, we provided a 
discussion in the proposed rule of four packaging level options that 
were considered for the CY 2007 OPPS update.
    One of the packaging options we considered for the CY 2007 OPPS 
update was to pay separately for all drugs, biologicals, and 
radiopharmaceuticals with a HCPCS code. We determined that this would 
be a straightforward policy that would speed the creation of procedural 
APC medians; however, we expressed concern that this policy would be 
inconsistent with OPPS packaging principles, would reduce hospitals' 
incentives for economy and efficiency, and would increase hospitals' 
administrative burden related to separate billing for more drugs, 
biologicals, and radiopharmaceuticals.
    During the August 2006 meeting of the APC Panel, the Panel endorsed 
this option and recommended that CMS eliminate the drug packaging 
threshold for all drugs and radiopharmaceuticals with HCPCS codes. We 
include our response to the Panel's recommendation in our discussion 
below.
    In addition to the APC Panel's recommendation, we received several 
comments requesting that we pay separately for all drugs, biologicals 
and radiopharmaceuticals (or combination thereof) with HCPCS codes that 
are provided in the hospital outpatient department and payable under 
the OPPS.
    Comment: Two commenters acknowledged that unpackaging all drugs, 
biologicals and radiopharmaceuticals is inconsistent with the concept 
of a prospective payment system. However, one of these commenters 
contended that packaged items may not be fully accounted for in the 
OPPS ratesetting process, and these costs therefore may not appear in 
the final payment rates established for the primary service. For this 
reason, the commenter believed that the OPPS should pay separately for 
all drugs, biologicals, and radiopharmaceuticals. The commenter further 
asserted that the OPPS' inability to use multiple procedure bills 
exacerbates the problem because multiple procedure claims are more 
likely to include packaged drugs, biologicals, and 
radiopharmaceuticals.
    Response: We agree that unpackaging all drugs, biologicals and 
radiopharmaceuticals is inconsistent with the concept of a prospective 
payment system. We have not been presented with any data that support 
the commenter's assertion that multiple procedure claims would be more 
likely to include packaged drugs, biologicals, and 
radiopharmaceuticals. Multiple procedure claims contain a variety of 
services, including surgical procedures, diagnostic imaging tests, 
visits, and laboratory procedures that also could have significant 
associated packaging in addition to drugs, biologicals, and 
radiopharmaceuticals, such as devices, minor ancillary procedures, 
anesthesia, operating room time, and recovery room time. As we have 
previously indicated, we are unable to use these claims for ratesetting 
because we cannot attribute the packaging appropriately to the 
individual services on the claims. However, we would not expect the 
amount of drug, biological, and radiopharmaceutical packaging to be 
proportionately higher for these multiple procedure claims compared to 
the amount of drug packaging contained on the single drug 
administration claims we use for ratesetting. In fact, we might expect 
that the percentage of total costs related to packaged drugs on these 
multiple claims to be significantly less than the comparable percentage 
for single claims for drug administration services. In addition, much 
of the packaged drug costs on multiple procedure claims might be more 
accurately associated with services other than drug administration 
services. Thus, we are unsure about the appropriate methodology and the 
ultimate utility of studies to examine drug, biological, and 
radiopharmaceutical packaging on multiple claims. In section VIII.C. of 
this preamble, we provide a preliminary analysis of a study we 
performed in response to the APC Panel's March 2006 recommendation to 
further explore how packaged drug, biological, and radiopharmaceutical 
costs are accounted for within the OPPS ratesetting methodology so that 
their costs are incorporated into payment rates for associated drug 
administration procedures. The same analysis provides a preliminary 
response to the APC Panel's August 2006 recommendation that CMS provide 
claims analysis of the contributions of packaged costs (considering 
packaged drugs and other packaging) to the median cost of each drug 
administration service.
    Comment: Several commenters asserted that separate payment for all 
drugs and biologicals under the OPPS was appropriate in the light of 
CMS's efforts to align payments across the physician office and 
hospital outpatient settings, for example, by adopting the ASP 
methodology in both settings. The commenters stated that continuing a 
policy of packaging certain items in the hospital outpatient setting 
would continue an inequality in payment between these settings. We also 
received several comments specifically against our proposal to set the 
packaging threshold for radiopharmaceuticals at $55. These commenters 
requested that we pay separately for all radiopharmaceuticals.
    Response: While we believe that payment parity is appropriate for 
certain items in order to provide appropriate access to care without 
undesirable site of service shifts, the OPPS and MPFS are fundamentally 
different payment systems with essential differences in their payment 
policies. Specifically, the OPPS is a prospective payment system, based 
on the concept of paying for groups of services that share clinical and 
resource characteristics. Payment is made in the OPPS according to 
prospectively established payment rates that are related to the 
relative costs of hospital resources for services. The MPFS is a fee 
schedule that generally provides payment for each individual

[[Page 68085]]

component of a service. Differences in the degrees of packaged payment 
and separate payment between these two systems are only to be expected. 
In general, we do not believe that our packaging methodology under the 
OPPS creates issues that result in limiting beneficiary access to care. 
In those rare circumstances where we believe a situation may cause 
problems with beneficiary access or where our packaging methodology may 
unduly influence physicians' treatment decisions, in the best interest 
of Medicare beneficiaries, we have modified our packaging methodology, 
as is the case for 5HT3 anti-emetics. At this time there is neither 
sufficient reason, nor have we been presented with information, that 
leads us to consider modifying our packaging policy for 
radiopharmaceuticals.
    Comment: Several commenters disagreed with our assertion that 
unpackaging all drugs and biologicals with HCPCS codes would increase 
the burden on hospitals, as many hospitals are following CMS' request 
to report charges for all drugs, biologicals, and radiopharmaceuticals 
with HCPCS codes, regardless of the packaging status of the particular 
item. However, another commenter agreed with our statement and 
explained that eliminating the packaging threshold for drugs, 
biologicals and radiopharmaceuticals would not only increase the 
administrative burden of hospitals, but that this change would lead to 
unexpected payment decreases for other services payable under the OPPS, 
because the OPPS is a budget neutral payment system.
    Response: We appreciate these comments. We understand that the 
impact of increased coding responsibilities that would accompany a 
change in our packaging policy would likely vary from hospital to 
hospital. We appreciate the efforts of hospitals to include data for 
packaged services on their claims as it continues to provide us with a 
robust data set which we can use for both future ratesetting and 
development of OPPS payment policies.
    We note that in CYs 2005 and 2006, the statutorily mandated drug 
packaging threshold was set at $50, and we believe it is appropriate to 
continue a modest drug packaging threshold for the CY 2007 OPPS, 
consistent with the framework provided in the law. Therefore, because 
of our continued belief that packaging is a fundamental component of a 
prospective payment system that contributes to important flexibility 
and efficiency in the delivery of high quality outpatient hospital 
services, we are not adopting the option of paying separately for all 
drugs, biologicals, and radiopharmaceuticals for CY 2007. Accordingly, 
we also are not adopting the August 2006 APC Panel recommendation 
presented above.
    The second option we presented in the CY 2007 proposed rule was to 
increase the packaging threshold to a level much higher than the 
current $50 threshold. As we discussed, we believed that this option 
would be more consistent with OPPS packaging principles by packaging 
more drugs, biologicals, and radiopharmaceuticals. In addition, we 
stated that we believed this option would also provide greater 
administrative simplicity for hospitals. However, we expressed concern 
that implementation of this option might result in circumstances where 
drug administration payments could be less than the cost of the 
packaged drugs, as relatively expensive drugs, biologicals, and 
radiopharmaceuticals could become packaged under this option.
    We received no comments on this option and we are not adopting this 
methodology for CY 2007.
    The third option we presented in the CY 2007 proposed rule was to 
maintain the packaging threshold at $50. We discussed that maintaining 
the threshold would provide stability to the payment system, as the 
packaging threshold has been set at $50 since CY 2004. We also noted 
that this policy option would be consistent with the March 2006 APC 
Panel recommendation to maintain the packaging threshold at $50 in CY 
2007. However we discussed our concern that this policy would not take 
into account price inflation and would, therefore, not be 
representative of real dollars in future years. We received one comment 
specifically on this option and a number of comments requesting this 
option if we decided to continue with a packaging methodology for the 
OPPS for CY 2007.
    Comment: One commenter supported the March 2006 APC Panel 
recommendation to retain the $50 packaging threshold because it would 
help ensure adequate payments for hospitals, preserve stability in the 
payment policy, and continue to provide beneficiary access to care.
    Response: We appreciate the commenter's support of the adequacy of 
the $50 threshold for drugs, biologicals, and radiopharmaceuticals. 
However, we have chosen to not to adopt this option, for the reasons 
discussed below.
    The final option discussed in the CY 2007 proposed rule was a 
variation of the previous option, where we proposed an annual update of 
the packaging threshold for inflation using an inflation adjustment 
factor based on the Producer Price Index (PPI) for prescription 
preparations. As described in the proposed rule, we calculated an 
adjusted packaging threshold for CY 2007 by using the four quarter 
moving average PPI levels for prescription preparations to trend the 
$50 threshold forward from the third quarter of CY 2005 (when the Pub. 
L. 108-173-mandated threshold became effective) to the third quarter of 
CY 2007. We proposed to apply an annual inflation adjustment factor 
that would be consistent with the practices of many health care payment 
policy areas, and many other areas of government policy, that 
acknowledge real costs by using an inflation adjustment factor instead 
of static dollar values. We discussed our concern that in the absence 
of a mechanism to update the threshold, we believed that current 
relatively inexpensive drugs would begin to receive separate payment 
over time.
    The PPI for prescription preparations reflects price changes at the 
wholesale or manufacturer stage. Because OPPS payment rates for drugs 
and biologicals are generally based on the average sales price (ASP) 
data that are reported by their manufacturers, in the proposed rule we 
indicated that we believed that the PPI for prescription preparations 
would be an appropriate price index to use to update the packaging 
threshold for CY 2007 and beyond.
    Specifically, we proposed to adjust the packaging threshold by the 
PPI for prescription drugs each year, and round the adjusted dollar 
amount to the nearest $5 increment to identify the updated packaging 
threshold. We calculated the adjusted amount for CY 2007 at $55.99, 
rounded to $55. Therefore, for CY 2007 and beyond, we proposed to 
package all drugs, biologicals, and radiopharmaceuticals whose per day 
cost is less than or equal to $55 into the procedures with which they 
are billed.
    We explained that we believed that this proposal was consistent 
with the APC Panel's March 2006 recommendation to continue the $50 
packaging threshold in CY 2007, because the real dollar value would be 
held constant during the calendar year in which it would be in effect. 
Our response to this recommendation is included in the discussion 
presented below.
    We received several comments on our proposal to provide an annual 
update of the packaging threshold using the four-quarter moving average 
PPI.
    Comment: Most commenters, in general, disagreed with an increase to 
the packaging threshold. However, one commenter disagreed with our use 
of

[[Page 68086]]

the PPI as a basis for our annual packaging threshold update. The 
commenter explained that as the PPI includes information for all 
prescription medications, it includes information for drugs that are 
not covered under Part B benefits and may inaccurately represent the 
amount of inflation for Part B drugs. The commenter recommended that 
CMS calculate an inflation index using manufacturers' quarterly ASP 
data submissions.
    Response: We appreciate the commenter's analysis of the 
applicability of the PPI and their proposed alternative methodology. 
There are a wide array of drugs that are covered under Part B of 
Medicare, and these drugs are used to treat a broad spectrum of 
clinical conditions in the hospital outpatient setting. These drugs 
range from monoclonal antibody agents, to complex chemotherapeutic 
agents, to antiemetics, to antibiotics, to narcotics, and to 
analgesics. The ASP system is relatively new, and we have only limited 
experience in following changes in manufacturers' data submissions over 
time. While we understand that the PPI includes drugs that may not be 
payable as a Part B benefit, we continue to believe that the PPI is a 
mature, well-established, and widely available index already used by 
Medicare that provides the most accurate estimate of Part B drug 
inflation for purposes of updating the OPPS drug packaging threshold 
each year. We intend to evaluate the applicability of the PPI as the 
drug packaging inflation adjustment factor as needed.
    Because we believe that packaging certain items is a fundamental 
component of a prospective payment system, that packaging these items 
does not lead to beneficiary access issues and does not create a 
problematic site of service differential, that a minimum $50 packaging 
threshold is reasonable based on its initial establishment in law for 
the CY 2005 OPPS, that updating the $50 threshold is consistent with 
industry and government practices, and that the PPI is an appropriate 
mechanism to gauge Part B drug inflation, we are finalizing our 
proposal to calculate an annual update to the OPPS packaging threshold 
using the proposed methodology without modification. Therefore, for CY 
2007 and beyond, drugs, biologicals and radiopharmaceuticals that are 
not new and do not have pass-through status will be packaged if their 
calculated per day cost is equal to or less than $55 for CY 2007 or 
equal to or less than the updated threshold established, rounded to the 
nearest $5 increment, for the relevant update year.
    To determine their CY 2007 proposed packaging status, we calculated 
the per day cost of all drugs, biologicals, and radiopharmaceuticals 
that had a HCPCS code in CY 2005 and were paid (via packaged or 
separate payment) under the OPPS using claims data from January 1, 2005 
to December 31, 2005. In CY 2005, multisource drugs and 
radiopharmaceuticals had two HCPCS codes that distinguished the 
innovator multisource (brand) drug or radiopharmaceutical from the 
noninnovator multisource (generic) drug or radiopharmaceutical. We 
aggregated claims for both the brand and generic HCPCS codes in our 
packaging analysis of these multisource products. In order to calculate 
the per day cost for drugs, biologicals, and radiopharmaceuticals to 
determine their packaging status in CY 2007, we proposed to use the 
methodology that was described in detail in the CY 2006 OPPS proposed 
rule (70 FR 42723 through 42724) and finalized in the CY 2006 OPPS 
final rule with comment period (70 FR 68636 through 68638).
    In our calculation of per day costs for the CY 2007 OPPS proposed 
rule we used the manufacturer-submitted ASP data from the fourth 
quarter of CY 2005 (rates that were used for payment purposes in the 
physician office setting effective April 1, 2006) and a payment rate of 
ASP+5 percent, as our proposal was to pay for drugs and biologicals at 
ASP+5 percent for CY 2007. For items that did not have an ASP-based 
payment rate, we used their mean unit cost derived from the CY 2005 
hospital claims data to determine their per day cost. For the proposed 
rule, we identified the items with per day cost less than or equal to 
$55 as packaged and identified items with per day cost greater than $55 
as separately payable.
    Our policy during previous cycles of the OPPS has been to use 
updated data to establish final determinations of the packaging status 
of drugs, biologicals, and radiopharmaceuticals. We note it is also our 
policy to make an annual packaging determination at the time of the 
final rule. Only items that are identified as separately payable will 
be subject to quarterly updates as discussed in section V.B.3. of this 
preamble. Items that are finalized as packaged will be eligible for 
consideration of separate payment only for the next update of the OPPS. 
We proposed to use the ASP data from the first quarter of CY 2006 
(reflected in payment rates in the physician office setting effective 
July 1, 2006) as a basis for our annual packaging determination for CY 
2007, along with updated hospital claims data from CY 2005, to 
determine the final per day costs of drugs, biologicals, and 
radiopharmaceuticals and their packaging status in CY 2007. As 
discussed in section V.B.3. of this preamble, for this CY 2007 final 
rule determination of packaging status we are also altering the payment 
rate used for the determination to reflect a payment rate of ASP+6 
percent, based on our final CY 2007 policy, rather than the proposed 
rate of ASP+5 percent.
    Because the data we used in the proposed rule to calculate per day 
costs, and the payment rates applied to that data, have been updated 
for the final rule packaging status determination, the packaging status 
of certain drugs, biologicals, and radiopharmaceuticals may have 
changed. Under such circumstances, we proposed to apply the following 
policies to these drugs, biologicals, and radiopharmaceuticals whose 
relationship to the $55 threshold changed based on the final updated 
data:
     Drugs, biologicals, and radiopharmaceuticals that were 
paid separately in CY 2006 (which were proposed for separate payment in 
CY 2007), and then have per day costs less than $55 based on the 
updated ASPs and hospital claims data used for the CY 2007 final rule 
with comment period, would continue to receive separate payment in CY 
2007.
     Drugs, biologicals, and radiopharmaceuticals that were 
packaged in CY 2006, (which were proposed for separate payment in CY 
2007), and then have per day costs less than $55 based on the updated 
ASPs and hospital claims data used for the CY 2007 final rule with 
comment period, would remain packaged in CY 2007.
     Drugs, biologicals, and radiopharmaceuticals for which we 
proposed packaged payment in CY 2007 but then had per day costs greater 
than $55 based on the updated ASPs and hospital claims data used for 
the CY 2007 final rule with comment period, would receive separate 
payment in CY 2007.
    We received no comments on the methodology we proposed to use in 
the event that the packaging status of a drug had changed due to the 
data update between the proposed and final rules. Therefore, we are 
finalizing this proposal without modification. Table 24 below indicates 
those drugs, biologicals and radiopharmaceuticals that have changed 
packaging status between the proposed rule and the final rule, and 
indicates their final CY 2007 packaging status.

[[Page 68087]]



                         Table 25.--Anti-Emetics Exempted from $55 Packaging Requirement
----------------------------------------------------------------------------------------------------------------
            HCPCS code               Short description
--------------------------------------------------------
J1260............................  Dolasetron mesylate.
J1626............................  Granisetron HCl
                                    injection..
J2405............................  Ondansetron HCl
                                    injection..
J2469............................  Palonosetron HCl....
Q0166............................  Granisetron HCl 1 mg
                                    oral..
Q0179............................   Ondansetron HCl 8
                                    mg oral..
Q0180............................  Dolasetron mesylate
                                    oral..
----------------------------------------------------------------------------------------------------------------

3. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without 
Pass-Through Status That Are Not Packaged
a. Payment for Specified Covered Outpatient Drugs
(1) Background
    Section 1833(t)(14) of the Act, as added by section 621(a)(1) of 
Pub. L. 108-173, requires special classification of certain separately 
paid radiopharmaceuticals, drugs, and biologicals and mandates specific 
payments for these items. Under section 1833(t)(14)(B)(i) of the Act, a 
``specified covered outpatient drug'' is a covered outpatient drug, as 
defined in section 1927(k)(2) of the Act, for which a separate APC 
exists and that either is a radiopharmaceutical agent or is a drug or 
biological for which payment was made on a pass-through basis on or 
before December 31, 2002.
    Under section 1833(t)(14)(B)(ii) of the Act, certain drugs and 
biologicals are designated as exceptions and are not included in the 
definition of ``specified covered outpatient drugs.'' These exceptions 
are--
     A drug or biological for which payment is first made on or 
after January 1, 2003, under the transitional pass-through payment 
provision in section 1833(t)(6) of the Act.
     A drug or biological for which a temporary HCPCS code has 
not been assigned.
     During CYs 2004 and 2005, an orphan drug (as designated by 
the Secretary).
    Section 1833(t)(14)(A)(iii) of the Act, as added by section 
621(a)(1) of Pub. L. 108 173, requires that payment for specified 
covered outpatient drugs in CY 2006 and subsequent years be equal to 
the average acquisition cost for the drug for that year as determined 
by the Secretary subject to any adjustment for overhead costs and 
taking into account the hospital acquisition cost survey data collected 
by the Government Accountability Office (GAO) in CYs 2004 and 2005. If 
hospital acquisition cost data are not available, the law requires that 
payment be equal to payment rates established under the methodology 
described in section 1842(o), section 1847A, or section 1847B of the 
Act as calculated and adjusted by the Secretary as necessary.
    For CY 2006, we adopted a policy of paying for the acquisition and 
overhead costs of separately paid drugs and biologicals at a combined 
rate of ASP+6 percent. To calculate the ASP+6 percent payment rate, we 
evaluated the three data sources that were available to us for setting 
the CY 2006 payment rates for drugs and biologicals. As described in 
the CY 2006 OPPS final rule with comment period (70 FR 68639 through 
68644), these data sources were the GAO reported average purchase 
prices for 55 specified covered outpatient drug categories for the 
period July 1, 2003, to June 30, 2004, collected via a survey of 1,400 
acute care Medicare-certified hospitals; ASP data; and mean costs 
derived from CY 2004 hospital claims data. For the CY 2006 final rule 
with comment period, we used ASP data from the second quarter of CY 
2005, which were used to set payment rates for drugs and biologicals in 
the physician office setting effective October 1, 2005.
    In our data analysis for the CY 2006 OPPS final rule with comment 
period, we compared the payment rates for

[[Page 68088]]

drugs and biologicals using data from all three sources described 
above. We estimated aggregate expenditures for all drugs and 
biologicals that would be separately payable in CY 2006 and for the 55 
drugs and biologicals reported by the GAO using mean costs from the 
claims data, the GAO mean purchase prices, and the ASP-based payment 
amounts (ASP+6 percent in most cases), and then calculated the 
equivalent average ASP-based payment rate under each of the three 
payment methodologies. We excluded radiopharmaceuticals in our analysis 
because they were paid at hospital charges reduced to cost during CY 
2006. The results based on updated ASP and claims data were published 
in Table 24 of the CY 2006 OPPS final rule with comment period. For a 
full discussion of our reasons for using these data, refer to section 
V.B.3.a. of the CY 2006 OPPS final rule with comment period (70 FR 
68639 through 68644).
    As we noted in the CY 2006 OPPS final rule with comment period, 
findings from a MedPAC survey of hospital charging practices indicated 
that hospitals set charges for drugs, biologicals, and 
radiopharmaceuticals high enough to reflect their pharmacy handling 
costs as well as their acquisition costs. In consideration of this 
information, we stated in the CY 2006 OPPS final rule that payment 
rates derived from hospital claims data also included acquisition and 
pharmacy handling costs because they are derived directly from hospital 
charges. Therefore, in CY 2006, we finalized a policy of providing 
payment to hospital outpatient departments for drugs, biologicals and 
associated pharmacy handling costs at a rate of ASP+6 percent.
(2) Payment Policy for CY 2007
    The provision in section 1833(t)(14)(A)(iii) of the Act, as 
described above, continues to be applicable to determining payments for 
specified covered outpatient drugs for CY 2007. This provision requires 
that in CY 2007 payment for specified covered outpatient drugs be equal 
to the average acquisition cost for the drug for that year as 
determined by the Secretary subject to any adjustment for overhead 
costs and taking into account the hospital acquisition cost survey data 
collected by the Government Accountability Office (GAO) in CYs 2004 and 
2005. If hospital acquisition cost data are not available, the law 
requires that payment be equal to payment rates established under the 
methodology described in section 1842(o), section 1847A, or section 
1847B of the Act as calculated and adjusted by the Secretary as 
necessary. Additionally, section 1833(t)(14)(E)(ii) authorizes the 
Secretary to adjust APC weights for specified covered outpatient drugs 
to take into account the MedPAC report relating to overhead and related 
expenses, such as pharmacy services and handling costs.
    For the CY 2007 OPPS proposed rule, we evaluated the two data 
sources that were available to us for ratesetting purposes for drugs 
and biologicals in CY 2007. The first source presented in the proposed 
rule was based on the ASP methodology and included data from the fourth 
quarter of CY 2005, which were also the data used for payments in the 
physician office setting effective April 1, 2006. We stated that we 
have prices for approximately 500 drugs and biologicals (including 
contrast agents) payable under the OPPS using the ASP methodology 
(ASP+6 percent in most cases); however, we did not have any data from 
this source for radiopharmaceutical products.
    The second source of cost data for drugs, biologicals, and 
radiopharmaceuticals discussed in the OPPS proposed rule available for 
ratesetting purposes was CY 2005 hospital claims data, used to 
calculate mean and median costs for these items. As section 
1833(t)(14)(A)(iii) of the Act clearly specifies that payment for 
specified covered outpatient drugs in CY 2007 be equal to the 
``average'' acquisition cost for the drug, we limited our analysis to 
the mean costs of drugs determined using the hospital claims data.
    To determine our proposed payment rates for drugs and biologicals 
for CY 2007, we compared estimated aggregate expenditures for all drugs 
and biologicals (excluding radiopharmaceuticals) that would be 
separately payable in CY 2007 using data from both sources described 
above. We then used the OPPS proposed conversion factor to calculate 
weights for each separately payable drug and biological HCPCS code and 
developed an equivalent average ASP-based payment rate under both 
payment methodologies. The result of this analysis indicated that using 
mean unit cost to set the payment rates for the drugs and biologicals 
that would be separately payable in CY 2007 would be equivalent to 
basing payment rates for these drugs and biologicals, on average, at 
ASP+5 percent. We again stated that this payment rate was 
representative of both hospital acquisition costs and pharmacy handling 
costs, as this ASP-based rate was calculated using hospital charge 
data, and hospital charges are inclusive of both acquisition costs and 
pharmacy handling costs for the particular drug. Therefore, for CY 
2007, we proposed a policy of paying for the acquisition and overhead 
costs of separately paid drugs and biologicals at a combined rate of 
ASP+5 percent.
    We received several comments on our proposal to use these two data 
sources to calculate an average ASP-based payment rate for separately 
payable drugs and biologicals in the hospital outpatient department for 
CY 2007.
    Comment: We received mixed comments about our proposal to continue 
to base OPPS payment rates for drugs and biologicals relative to the 
ASP methodology. A few commenters expressed their dissatisfaction with 
certain aspects of the ASP system, and as a result, our use of a 
payment rate relative to ASP. These commenters expressed concern that 
ASP rates reflect prompt pay discounts that hospitals do not 
experience, that the data represented by ASP reporting do not indicate 
hospital-specific prices, and that the inclusion of 340B prices skews 
ASP data because only a limited number of hospitals are eligible to 
receive these reduced prices. Other commenters who disagreed with our 
proposal to use the ASP methodology suggested that we conduct a survey 
to collect data on hospital acquisition costs and include factors such 
as size and type of hospital. However, other commenters expressed 
support of our continued use of the ASP-based methodology in the OPPS.
    Response: We note that the ASP methodology has been established 
through rulemaking, and specific requests regarding methodological 
changes to this established system are outside the scope of this final 
rule with comment period. In addition, we note that we received 
numerous supportive comments regarding our proposal to use ASP as the 
basis for hospital payments in the OPPS for CY 2006. At that time, 
commenters generally supported the use of ASP as a payment methodology 
because these rates are updated quarterly and are therefore more 
reflective of current market conditions that influence hospital 
purchasing prices than hospital claims data, and payment equity across 
the hospital and physician office settings offers administrative 
benefits and does not create a site-of-service difference. Furthermore, 
comparison of the ASP data to our hospital claims data serves to ensure 
that we are paying for drugs in the OPPS in general at rates that are 
reflective of hospitals costs for acquisition and overhead. For these 
reasons, we continue to believe that ASP is an appropriate proxy of the

[[Page 68089]]

average acquisition and pharmacy overhead costs for drug and 
biologicals administered in the hospital outpatient setting.
    Comment: Several commenters also addressed our methodology for 
determining the specific ASP-based payment rate including acquisition 
costs and pharmacy handling costs for separately payable drugs and 
biologicals that would equate to payment of drugs and biologicals based 
on their mean costs from claims data. Some commenters were confused 
about how our methodology resulted in a proposed payment at ASP+5 
percent for CY 2007, while others disagreed with our methodology to 
only include separately payable drugs and biologicals in our 
calculations. The commenters theorized that due to hospital charge 
compression, pharmacy overhead costs for inexpensive drugs that are 
typically packaged under the OPPS exhibit a higher pharmacy handling 
cost relative to their acquisition cost because hospitals 
disproportionately load their pharmacy overhead costs in their charges 
for less costly drugs. Therefore, while hospitals may attribute costs 
associated with pharmacy services across all drugs, the costs 
associated with a particular drug do not necessarily encompass that 
drug's total pharmacy handling costs. The commenters believed that this 
results in an inaccurate ASP-based estimate for drugs and biologicals 
in the OPPS, because these lower cost packaged drugs that have 
proportionately greater pharmacy overhead costs in their charges are 
not used in our calculation, which is based only on those drugs with 
per day costs greater than the $55 packaging threshold.
    Response: We included a detailed explanation of the methodology we 
used to determine our proposed average CY 2007 ASP-based payment 
inclusive of acquisition and pharmacy handling costs in the proposed 
rule (71 FR 49584), and we again discussed this methodology relative to 
the CY 2007 final ratesetting process above. We began our analysis by 
identifying those drugs and biologicals that we have determined will 
receive separate payment in CY 2007. (See section V.B.2. of this final 
rule with comment period for a discussion of the methodology we used to 
determine the packaging status for drugs, biologicals, and 
radiopharmaceuticals for CY 2007.) We do not include packaged drugs and 
biologicals in this analysis because cost data for these items are 
already accounted for within the APC rates setting process through the 
methodology discussed in section II.A. of this preamble. To include the 
costs of packaged drugs in both our APC ratesetting process (for 
associated procedures present on the same claim) and during our 
ratesetting process to establish a relative ASP-based payment amount 
for drugs and biologicals would give this data disproportionate 
emphasis in the OPPS system by skewing our analyses, as the costs of 
these packaged items would be, in effect, counted twice. Once we 
determined our final CY 2007 packaging policy for drugs, biologicals, 
and radiopharmaceuticals at a packaging threshold of $55 or less per 
day, we included the costs of these packaged drugs and biologicals in 
the standard OPPS calculation of procedural APC median costs. 
Accordingly, we are not implementing the suggestion from commenters 
that we include all packaged and separately payable drugs and 
biologicals when establishing an average ASP-based rate to provide 
payment for the hospital acquisition and pharmacy handling costs of 
drugs and biologicals. However, we remind commenters that because the 
costs of packaged drugs, including their pharmacy overhead costs, are 
packaged into the payments for the procedures in which they are 
administered, the OPPS provides payment for both the drugs and the 
associated pharmacy overhead costs through the applicable procedural 
APC payments.
    We noted that ASP data were unavailable for some drugs and 
biologicals at the time of the proposed rule, and some remain 
unavailable at the time of this final rule. For these drugs and 
biologicals, we proposed to use their mean unit costs from the CY 2005 
hospital claims data to determine their packaging status for 
ratesetting. In addition, we proposed to base payment for these drugs 
and biologicals on their mean cost calculated from CY 2005 hospital 
claims data until ASP-based rates become available for these items.
    Comment: One commenter requested that CMS use a drug's WAC or AWP 
data in order to determine an item's packaging status when ASP data are 
unavailable.
    Response: We follow the established ASP methodology, and the ASP 
methodology incorporates several sources, such as WAC and AWP, as well 
as ASP data submitted by manufacturers. Additional information on the 
ASP methodology can be found at: http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage.
    We noted in the proposed rule that we determine the packaging 
status of each drug or biological for the following year only once 
during the annual update process; however, those drugs and biologicals 
that we determine will be separately payable during the next calendar 
year will receive quarterly updates to their ASP-based payment rates, 
as is the current process in both the OPPS and physician office 
setting. We indicated that in CY 2007, we will continue to post these 
quarterly payment rate changes on our Web site.
    During the March 2006 meeting of the APC Panel, the Panel 
recommended that CMS examine pharmacy overhead costs issues and work 
with appropriate associations to study how to measure pharmacy overhead 
costs. The Panel also recommended that CMS solicit feedback on how 
pharmacy overhead costs should be reimbursed in the future.
    In the proposed rule, we responded to these recommendations by 
stating that we would continue to work on issues related to pharmacy 
overhead costs, and we specifically requested public comments on 
methodologies that could be used when considering pharmacy overhead 
cost issues in future years. We again note that we regularly accept 
requests from interested organizations to discuss their views about 
OPPS payment policy issues, including pharmacy handling issues. As 
stated in our CY 2007 OPPS proposed rule (71 FR 49585), we consider the 
input of any individual or organization to the extent allowed by 
Federal law, including the Administrative Procedure Act (APA) and the 
Federal Advisory Committee Act (FACA). In addition, we establish the 
OPPS rates through regulations, and as such we are required to consider 
the timely comments of interested organizations, establish the payment 
policies for the forthcoming year, and respond to the timely comments 
of all public commenters in the final rule in which we establish the 
payments for the forthcoming year.
    The APC Panel recommended at its August 2006 meeting that CMS work 
with stakeholders to better understand the costs involved in the 
preparation of pharmaceutical agents for chemotherapy, and that CMS 
work to develop a new payment methodology that acknowledges and 
provides appropriate payment for those costs. The Panel requested a 
report on our findings at their next meeting. We will provide an update 
to the Panel on all the information that has been shared with us at 
their next meeting.
    We received many comments in response to our request for 
information related to hospital outpatient department pharmacy overhead 
costs.
    Comment: A number of commenters expressed dissatisfaction with the

[[Page 68090]]

amount of pharmacy handling costs represented in the methodology that 
resulted in an aggregate payment for drug acquisition and pharmacy 
handling costs at ASP+6 percent in CY 2006. The commenters noted 
increased pharmacy costs, such as unfunded mandates, increased staff 
training in order to handle complex drugs, and multiple demands on the 
time of pharmacists, including quality verification requirements and 
patient or physician consultations, that contribute to pharmacy 
handling costs that are above the amount represented by the ASP+6 
methodology after subtracting drug acquisition costs. Several of these 
commenters expressed disappointment that CMS had not implemented an 
administratively simple methodology for collecting hospital pharmacy 
overhead cost data that could be used as the basis for providing 
additional payments for pharmacy handling costs.
    Several commenters also expressed concern that the proposed payment 
of ASP+5 percent for CY 2007 would not be adequate to cover both the 
acquisition costs and pharmacy handling costs associated with drug 
services provided in a hospital outpatient department setting. One 
commenter suggested that CMS should, at a minimum, implement the two 
percent add-on payment that was discussed in the CY 2006 OPPS proposed 
rule. Others suggested various add-on payments, with amounts ranging 
from $10 for every billed drug, to inflating OPPS payment rates for 
separately payable drugs and biologicals to ASP+39 percent.
    MedPAC expressed concern that our proposal to pay for drugs and 
biologicals at ASP+5 percent, a proportional payment methodology, could 
result in inaccurate payments for individual drugs because it does not 
effectively account for large differences in pharmacy overhead costs 
among drugs. MedPAC recommended that payment for pharmacy overhead 
costs should reflect methods recommended in their June 2005 Report to 
Congress to collect drugs into APC groups based on attributes that 
affect overhead costs and establish payment rates for the APCs based on 
hospital claims data. MedPAC encouraged us to revisit this issue and 
develop a method that recognizes and pays more specifically for the 
pharmacy overhead costs of different classes of drugs.
    Response: We appreciate these comments and recognize the concerns 
that were expressed related to identifying and providing accurate 
payments for hospital outpatient department costs for pharmacy handling 
services. We understand that not every hospital will be able to acquire 
all drugs for the same price, and to that end, we use aggregate amounts 
when determining the average ASP-based amount that applies across all 
drugs. We also acknowledge that different types of drugs likely have 
very disparate pharmacy handling costs.
    In the CY 2006 proposed rule, we proposed creating a set of HCPCS 
codes that hospitals would be able to use to indicate the relative 
resource levels of pharmacy handling involved in preparing a reported 
drug, biological, or radiopharmaceutical for administration. This 
methodology would have allowed us to begin collecting data on pharmacy 
overhead costs for possible use in future ratesetting calculations. We 
did not finalize this proposal for CY 2006 due to the overwhelming 
response from the hospital community citing the tremendous 
administrative burden reporting these pharmacy handling codes would 
have placed on hospital resources. Hospitals have now had 1 year to 
fully consider this proposal and it appears that there may be greater 
support for the creation of these pharmacy HCPCS codes, or another 
methodology to collect this data. We are reluctant to proceed with the 
implementation of our CY 2006 proposal until we are confident that 
there is not another feasible, less burdensome alternative or there is 
much broader support in the hospital community for this proposal. 
Therefore, we are not adopting this methodology for CY 2007. However, 
we again specifically request comments regarding hospital outpatient 
department pharmacy costs and request ideas and methodologies that we 
may consider for future data collection purposes under the OPPS.
    As we stated in our discussion of the average ASP-based methodology 
in CY 2006, and as we have reiterated above, it is our understanding 
that pharmacy handling costs are included in hospital charges for drugs 
and biologicals. Therefore, we continue to believe that without more 
information regarding the specific required resources and their 
associated costs for providing hospital outpatient department pharmacy 
handling services associated with particular groups of drugs, it is not 
reasonable to provide differential, identifiable payments for pharmacy 
handling services that are separate from our payments for the average 
acquisition costs of drugs. We believe that generally our methodology 
of providing a single payment level for drug acquisition and pharmacy 
overhead costs provides, in aggregate, appropriate payment to hospitals 
for both types of costs. This averaging methodology is fully consistent 
with the principles of a prospective payment system like the OPPS.
    Comment: One commenter suggested that CMS develop a survey for 
hospitals and instruct fiscal intermediaries to administer, collate, 
and transmit this data back to CMS where this information could then be 
used as the basis for an additional pharmacy add-on or separate APC 
payments for pharmacy services.
    Response: We appreciate the commenter's suggestions for gathering 
information regarding pharmacy overhead costs. We are not sure, 
however, that it would be administratively feasible and reasonable from 
a resource perspective to develop and update information regarding 
pharmacy overhead costs through a hospital survey administered by 
fiscal intermediaries. We are also concerned that such a survey could 
be quite burdensome for hospitals. We will continue to work with the 
hospital industry to better understand the costs associated with 
pharmacy overhead and drug handling, and we welcome additional 
suggestions for alternative approaches to gathering cost information to 
inform our policy development.
    Comment: One commenter requested that CMS convene an APC Panel 
meeting specific to the topics of pharmacy handling issues and charge 
compression.
    Response: We appreciate the commenter's suggestion. However, at 
this time, we do not believe that a special meeting of the APC panel on 
pharmacy overhead costs is necessary, since the topic has been included 
on the agenda of several recent Panel meetings, and has been the 
subject of extended discussions in the course of these meetings. 
Furthermore, the APC Panel's 2004 charter specifically states that the 
issue of cost compression is outside of the scope of the Panel. 
Additional information on the purpose and scope of the APC Panel is 
available at: http://www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassification[fxsp
0]Groups.asp.
    In its final report on the hospital acquisition cost survey of 
specified covered outpatient drugs entitled ``Medicare Hospital 
Pharmaceuticals: Survey Shows Price Variation and Highlights Data 
Collection Lessons and Outpatient Rate-Setting Challenges for CMS,'' 
the GAO recommended that the Secretary validate, on an occasional 
basis, manufacturers' reported drug ASPs as a measure of hospitals'

[[Page 68091]]

acquisition costs using a survey of hospitals or other method that CMS 
determines to be similarly accurate and efficient. As we indicated in 
our written comments to the GAO on its draft report, we will continue 
to consider the best approach for setting payment rates for drugs and 
biologicals in light of this recommendation. We also indicated that we 
would continue to analyze the adequacy of ASP-based pricing in light of 
our hospital claims data.
    In its October 31, 2005 letter of comment on proposed 2006 SCOD 
rates titled ``Comments on Proposed 2006 SCOD Rates,'' the GAO 
recommended that in order to approximate hospitals' acquisition costs 
of SCODs better, the Secretary should reconsider the level of proposed 
payment rates for drug SCODs, in relation to survey data on average 
purchase price, the role of rebates in determining acquisition costs, 
and the desirability of setting payment rates for SCODs at average 
acquisition costs. In the CY 2006 OPPS proposed rule (70 FR 42726), we 
noted that the comparison between the GAO purchase price data and the 
ASP data indicated that the GAO data on average were equivalent to 
ASP+3 percent. For the CY 2006 OPPS final rule with comment period, we 
found that the comparison between the GAO purchase price data and the 
ASP data indicated that the GAO data on average were equivalent to 
ASP+4 percent, and using mean unit cost from hospital claims to set the 
payment rates for the drugs and biologicals that would be separately 
payable in CY 2006 would be equivalent to basing their payment rates, 
on average, at ASP+6 percent. Because pharmacy overhead costs are 
already built into the charges for drugs, biologicals, and 
radiopharmaceuticals, we noted in the CY 2006 OPPS final rule with 
comment period that our claims data indicated that payment for drugs 
and biologicals and their pharmacy overhead at a combined ASP+6 percent 
rate served as the best proxy for the combined acquisition and overhead 
costs of each of these products.
    During the August meeting of the APC Panel, the Panel recommended 
that CMS maintain the payment rate for drugs and biologicals at ASP+6 
percent in the hospital outpatient setting for CY 2007. We discuss our 
responses to these recommendations below.
    We received a number of comments on our proposal to set the ASP-
based payment for separately payable drugs and biologicals provided in 
CY 2007 in the hospital outpatient setting at ASP+5 percent.
    Comment: The majority of comments we received regarding our CY 2007 
OPPS payment policy for drugs and biologicals expressed concern over 
the proposed rate of ASP+5 percent. Most commenters requested that we 
continue the ASP+6 percent methodology, or increase the ASP-based 
payment amount for separately payable drugs and biologicals under the 
OPPS for CY 2007. The commenters stated that the proposed ASP-based 
rate of ASP+5 percent was inadequate, citing difficulties obtaining 
drugs at this price and challenges identifying the portion of payment 
that was to account for pharmacy handling costs associated with these 
items. In addition, several commenters expressed that a difference in 
payment rates for drugs and biologicals across the hospital outpatient 
and physician office settings may result in an unexpected site of 
service shift that may be problematic for beneficiaries.
    The vast majority of commenters recommended that CMS retain the CY 
2006 rate of ASP+6 percent for drugs, biologicals and their associated 
pharmacy handling costs for CY 2007.
    Response: We appreciate these comments. In analyzing data for the 
CY 2007 final rule, we again performed the analysis described in the CY 
2007 proposed rule comparing aggregate expenditures for separately 
payable drugs and biologicals to the ASP-based payment rates, weighting 
these HCPCS codes by their OPPS volumes, and calculating an ASP-based 
average payment rate for drugs and biologicals provided in hospital 
outpatient departments for CY 2007. As we did for our final rule 
analysis to determine the final packaging status for each drug, we used 
updated CY 2005 hospital claims data, including updated CCRs and 
complete year CY 2005 mean unit costs and drug volumes. The result of 
our final analysis using updated hospital claims data for the full CY 
2005 year and updated CCRs indicates that the ASP-based average payment 
rate for separately payable drugs and biologicals, including pharmacy 
handling costs, would be the equivalent of ASP+4 percent for CY 2007. 
Thus, if we were to follow the methodology that we employed for 
establishing the payment rate for drugs and biologicals under the OPPS 
in the CY 2006 final rule and the CY 2007 proposed rule, we would set 
the CY 2007 payment rate for these items at ASP+4 percent.
    However, we have decided to accept the recommendation of the APC 
Panel and the recommendation of many commenters to continue to pay for 
the acquisition costs of separately payable drugs and biologicals and 
their associated pharmacy handling costs in the hospital outpatient 
department at a combined rate of ASP+6 percent for CY 2007. In 
addition, we are also finalizing our proposal to pay for separately 
payable drugs and biologicals without ASP-based data at their mean cost 
calculated from CY 2005 hospital claims data. We have adopted this 
final policy for CY 2007 for the reasons noted below. We continue to 
believe the MedPAC finding that pharmacy overhead costs are included in 
the hospital's charge for a drug, whether we treat the payment for the 
drug and its handling as packaged or separately payable. While our 
final rule analysis indicated an average ASP-based payment of ASP+4 
percent, we note that this is the same relative ASP-based amount that 
was comparable to the GAO purchase price data for a subset of drugs 
reviewed in our CY 2006 final rule with comment period, which did not 
include pharmacy overhead costs. This factor furthered our conclusion 
that a final payment determination of ASP+6 percent was a reasonable 
level of payment for both the hospital acquisition and pharmacy 
overhead costs of drugs and biologicals in CY 2007. We further believe 
maintaining stability in the payment levels for drug and biologicals 
should be considered in light of the inherent complexity in determining 
how to best account for pharmacy overhead costs.
    We also understand the commenters' concerns about providing 
appropriate OPPS payment for the costs of pharmacy overhead and drug 
handling, but believe a better understanding of the full nature and 
magnitude of hospitals costs related to these important activities is 
needed. Therefore, we will continue to work with the hospital industry 
to examine the difficult and complex issues concerning pharmacy 
overhead in the hospital outpatient department.
    Therefore, for these reasons, we are not finalizing our proposal to 
pay for drugs and biologicals at ASP+5 percent. Instead, after 
carefully considering all comments and the recommendations of the APC 
Panel, we are accepting the Panel's recommendation to continue to pay 
for separately payable drugs, biologicals and their associated pharmacy 
handling in the hospital outpatient department for CY 2007 at a 
combined rate of ASP+6 percent to maintain the stability of our 
payments. We believe that this rate will ensure suitable payment for 
the hospital pharmacy overhead costs associated with drugs and 
biologicals, while we continue to work with the hospital industry to 
understand the complex

[[Page 68092]]

issues related to capturing and evaluating these overhead costs. Full 
consideration of the potential benefits and challenges associated with 
alternative OPPS payment methodologies for hospitals' pharmacy overhead 
and drug handling costs that are associated with administering drugs 
and biologicals in the hospital outpatient department is an important 
part of this ongoing work.
    During the March 2006 meeting of the APC Panel, the Panel included 
several recommendations regarding intravenous immune globulin (IVIG) 
including: that CMS work with the Plasma Protein Therapeutics 
Association and other stakeholders to develop appropriate payments for 
IVIG; that CMS maintain separate payment for IVIG preadministration-
related services as long as it remains appropriate, and that CMS 
reevaluate payments for IVIG administration, especially considering the 
resource intensity of IVIG infusions. Our responses to these 
recommendations are included in our discussion below.
    Comment: Several commenters urged the continuation of the one-year 
temporary preadministration-related services fee for IVIG that we 
established for CY 2006. The commenters stated that there continue to 
be concerns with IVIG access and availability and that eliminating the 
fee will have an adverse impact on beneficiary access to care. 
Furthermore, some indicated that CMS provided little rationale in the 
proposed rule for why the fee was no longer needed.
    A number of commenters expressed concerns about the adequacy of 
Medicare's drug and drug administration payment rates for IVIG, and 
made some suggestions for changes to these payment rates that they have 
previously expressed to us. For example, some urged CMS to take actions 
such as establishing separate HCPCS codes for each IVIG product, 
increasing payment for IVIG administration and instituting a payment 
adjustment to the ASP-based payment rates for IVIG.
    One commenter provided information from a survey conducted of 800 
patients with primary immune deficiency syndrome. The commenter, a 
patient advocacy group, stated that since the beginning of 2005, 
Medicare patients receiving IVIG have been more likely than patients 
with other types of insurance to report a shift in site of care, 
increased intervals between infusions, reduced IVIG dosages, and 
adverse health effects, and they believe that this is the result of 
Medicare reimbursement issues.
    Response: We recognize the importance of IVIG to patients who need 
it, and we are concerned about reports of problems with IVIG access and 
availability. Since 2005, CMS has taken several specific actions that 
are within our statutory authority in response to the IVIG concerns 
that have been raised, including creating separate HCPCS codes to 
report lyophilized and non-lyophilized IVIG in April 2005, having 
discussions with manufacturers about their ASP data to confirm that 
their ASPs have been developed in accordance with applicable guidance, 
and for CY 2006 establishing a temporary additional payment for IVIG 
preadministration-related services to compensate physicians and 
hospital outpatient departments for extra resources expended on 
locating and obtaining appropriate IVIG products and on scheduling 
patients' infusions during a period where there may be temporary market 
instability. In addition, we continue to work with manufacturers, 
patient groups, and stakeholders to understand the present situation 
and to assess potential actions that could help ensure an adequate 
supply of IVIG and patients receiving appropriate, high quality care. 
We believe that these ongoing efforts will continue to assist us in 
developing future payment policies that continue to adapt to the IVIG 
marketplace. Therefore, we accept the Panel's recommendation to work 
with external stakeholders to develop appropriate payments for IVIG and 
related services.
    As these efforts are ongoing, we do not believe that specific 
adjustments to the ASP-based payment rates for IVIG are appropriate or 
necessary at this time. We remain confident that our ASP data reflect 
current market pricing for all of the brands of IVIG, and that our CY 
2007 final payment rates are appropriate for these therapies. 
Furthermore, there are currently two studies underway in the Department 
of Health and Human Services (HHS) concerning IVIG. The HHS Assistant 
Secretary for Planning and Evaluation has commissioned a study to 
better understand the market for IVIG and evaluate the demand, supply, 
and access to IVIG. The HHS Office of Inspector General is also 
conducting a study on availability and pricing of IVIG. We anticipate 
that these studies will provide more information on IVIG supply, 
demand, and pricing.
    With several studies on IVIG not yet completed and with comments 
from stakeholders suggesting that some beneficiaries are experiencing 
IVIG access issues such as delayed treatments and site of service 
shifts, we believe it is appropriate to continue the temporary IVIG 
preadministration-related services payment into CY 2007 to help ensure 
continued patient access to IVIG. We will continue to review IVIG 
access during CY 2007 as additional information becomes available, and 
we will discontinue this temporary preadministration-related services 
payment during CY 2007 through rulemaking if we determine it is no 
longer warranted.
    Therefore, after our assessment of the comments, we are also 
accepting the March 2006 recommendation of the APC Panel and the 
suggestion of several commenters to continue the IVIG 
preadministration-related services payment as long as it remains 
appropriate in CY 2007. Consequently, Medicare will temporarily allow a 
separate payment in CY 2007 for each day of IVIG administration to 
physicians and hospital outpatient departments that administer IVIG to 
Medicare beneficiaries. This payment is for the extra resources 
expended on locating and obtaining appropriate IVIG products and on 
scheduling patients' infusions during this time when there may continue 
to be transient disruptions in the marketplace. This preadministration-
related service payment will continue to be billed under the same HCPCS 
code as CY 2006: G0332 (Preadministration-related services for 
intravenous infusion of immunoglobulin, per infusion encounter). We are 
continuing our CY 2006 placement of HCPCS code G0332 in New Technology 
APC 1502 (status indicator ``S'') with a payment rate of $75 at this 
time. The payment for preadministration-related services is in addition 
to the separate payments Medicare makes for the IVIG product itself and 
its administration.
    We believe that continuation of this temporary separate payment 
provided through G0332 for the physician office and hospital outpatient 
resources associated with additional IVIG preadministration-related 
services will help facilitate beneficiary access to care in this 
current period where there may be continuing market fluctuations for 
IVIG products. At the same time, we will continue to work with the IVIG 
community, manufacturers, providers, and other stakeholders, and will 
be monitoring IVIG market developments and access to care closely.
    Additionally, regarding comments requesting the establishment of 
brand-specific HCPCS codes for IVIG products, we again remind the 
commenters that Level II HCPCS codes describe categories of similar 
items. The code set is not intended to be an exhaustive listing of all 
brands on the market. In CY

[[Page 68093]]

2006, we stated that we do not see a compelling reason to override that 
standard; this conclusion also holds true for CY 2007. (For further 
discussion of HCPCS coding procedures, see http://www.cms.hhs.gov/medicare/hcpcs/codpayproc.asp.)
    Commenters expressed concern regarding OPPS payment for both IVIG 
drugs and their administration. Typically, IVIG administration requires 
a multiple hour infusion and frequent monitoring by qualified hospital 
staff. As discussed above, the APC Panel recommended that we reevaluate 
IVIG administration payments, taking into consideration the additional 
resources associated with this type of therapy. We accepted this APC 
Panel recommendation and reevaluated the IVIG administration payments, 
along with our general review of drug administration methodology. We 
believe that our final drug administration payment policy for CY 2007, 
as discussed in section VIII. of this final rule with comment period, 
will provide more accurate payments for extended infusions, including 
IVIG infusions.
    Finally, we received several comments requesting that we classify 
IVIG therapy as a biological response modifier. We note that the term 
``biological response modifier'' is used in the text preceding CY 2006 
CPT codes, and as such, we refer commenters to the AMA CPT Editorial 
Panel, as they are the creators and maintainers of CPT codes and CPT 
code instructions.
    In CY 2005, we applied an equitable adjustment to determine the 
payment rate for darbepoetin alfa (HCPCS code Q0137) pursuant to 
section 1833(t)(2)(E) of the Act. However, for CY 2006 we transitioned 
to ASP-based payment rates for OPPS drugs and biologicals and stated 
that it was our intent to permit market forces to determine the 
appropriate payment rate for this biological. We received a few 
comments on our proposal to continue with an ASP-based payment rate for 
this biological.
    Comment: Commenters commended CMS on our decision to not exercise 
our equitable adjustment authority for any drug or biological in CY 
2007.
    Response: We appreciate the support of these commenters. As we 
discussed in CY 2006, we believe that as long as the market price for 
darbepoetin alfa is consistent with a payment rate derived using a 
clinically appropriate conversion ratio, invoking our equitable 
adjustment authority would not lead to a different result.
    During CY 2006, we provided payment for blood clotting factors 
under the OPPS at ASP+6 percent and included payment for the furnishing 
fee that is also a part of the payment for blood clotting factors 
furnished in physician offices under Medicare Part B. In the CY 2006 
OPPS final rule with comment period (70 FR 68661), we indicated that we 
would update the furnishing fee (based on the consumer price index) and 
the payment amount for this furnishing fee each calendar year so that 
the furnishing fee is equal to the amount noted in the MPFS final rule.
    Comment: One commenter requested that CMS establish brand-specific 
HCPCS codes for each available sodium hyaluronate product. In addition, 
they requested that each brand-specific HCPCS code be assigned to an 
individual APC, with assigned APC payment rates based on product-
specific ASP data. The commenter concluded that they believe that there 
is no scientific justification for the current three HCPCS code 
structure that assigns two products to individual HCPCS codes while 
other products are grouped together in a single HCPCS code.
    Response: We appreciate this comment, and the National HCPCS Panel 
agreed that a reconfiguration of these codes was warranted. The 
National HCPCS Panel has examined the sodium hyaluronate codes 
referenced by this comment and has concluded that all sodium 
hyaluronate products will be reported in CY 2007 with the single HCPCS 
code J7319 (Hyaluronan (Sodium hyaluronate) or derivative, intra-
articular injection, per injection). As we discuss in reference to 
pass-through drugs and biologicals in section V.A.3. of this final rule 
with comment period, it is our practice to adopt a national HCPCS code 
for reporting drugs when available, with the exception of certain pass-
through drug situations. Therefore, for services furnished on or after 
January 1, 2007, hospitals are to use the single HCPCS code for sodium 
hyaluronate products, J7319, status indicator ``K,'' to report all 
sodium hyaluronate intra-articular injections provided in hospital 
outpatient departments.
    As there is a single national HCPCS code, and there are no sodium 
hyaluronate products with pass-through status in CY 2007, this single 
HCPCS code will be assigned to a single APC for OPPS payment purposes. 
Therefore, for CY 2007, HCPCS code J7319 is assigned to APC 0896 
(Sodium Hyaluronate Injection). We have calculated a reference October 
2006 ASP-based payment rate for this single code at $124.68, as shown 
in Addenda A and B of this final rule with comment period.
    In the CY 2007 OPPS, we proposed to continue our CY 2006 policy of 
providing payment for blood clotting factors at a rate of ASP+5 percent 
plus an additional furnishing fee.
    We received four comments on our proposal regarding blood clotting 
factors.
    Comment: All commenters commended us on proposing to continue to 
pay the furnishing fee and urged us to continue providing payment for 
blood clotting factors under the OPPS at a rate equal to ASP+6 in CY 
2007.
    Three of these commenters additionally expressed concern that the 
proposed ASP-based rate for blood clotting factors would also be 
applied to the inpatient hospital setting. These commenters requested 
that if payment rates were adjusted in the outpatient setting that we 
not apply these rates to the inpatient hospital setting as well.
    Response: We appreciate these comments. As we proposed an ASP-based 
payment rate for CY 2007 of ASP+5 percent for separately payable drugs, 
biologicals and blood clotting factors in CY 2007, and we have since 
finalized a payment rate of ASP+6 percent for separately payable drugs 
and biologicals in this final rule, we are taking this opportunity to 
finalize a payment rate for separately payable blood clotting factors 
in the outpatient setting at ASP+6 percent plus the updated CY 2007 
furnishing fee of $0.15. Issues concerning inpatient hospital rates are 
outside the scope of this final rule with comment period, and we refer 
the commenters to the annual IPPS rulemaking process to note these 
concerns.
(3) CY 2007 Payment Policy for Radiopharmaceuticals
(a) Background and Proposed CY 2007 Radiopharmaceutical Payment Policy
    Section 303(h) of Public Law 108-173 exempted radiopharmaceuticals 
from ASP pricing in the physician office setting. In both the CY 2005 
and CY 2006 OPPS final rules with comment period, the OPPS exempted 
radiopharmaceutical manufacturers from reporting ASP data for payment 
purposes under the OPPS for reasons discussed in those rules (69 FR 
65811 and 70 FR 68655, respectively). Consequently, we did not have ASP 
data for radiopharmaceuticals for consideration for CY 2007 ratesetting 
in the OPPS.
    Pursuant to section 1833(t)(14)(B)(i)(I) of the Act, 
radiopharmaceuticals are classified under the OPPS as specified covered 
outpatient drugs (SCODs).

[[Page 68094]]

Accordingly, payments for radiopharmaceuticals are to be made at 
average acquisition cost as determined by the Secretary and subject to 
any adjustment for overhead costs. Radiopharmaceuticals are also 
subject to the policies affecting all similarly classified OPPS drugs 
and biologicals, such as pass-through payments and packaging 
determinations, as discussed earlier in this final rule with comment 
period.
    For CY 2006, we used CY 2004 mean unit cost data from hospital 
claims to determine each items' packaging status, and we implemented a 
1-year temporary policy to pay for separately payable 
radiopharmaceuticals based on the hospital's charge for each 
radiopharmaceutical adjusted to cost using the hospital's overall cost-
to-charge ratio. This temporary methodology was finalized as an interim 
proxy for average acquisition cost because of the unique circumstances 
associated with providing radiopharmaceutical products to Medicare 
beneficiaries. We clearly stated in the CY 2006 OPPS final rule with 
comment period that we did not intend to maintain the CY 2006 
methodology permanently (70 FR 68656), and that we would actively seek 
other methodologies for setting payments for radiopharmaceuticals in CY 
2007.
    In the CY 2006 final rule, we also discussed the various data 
sources available to us, as well as the challenges associated with 
developing an acceptable mechanism to identify average costs for 
radiopharmaceutical products. In addition, we stated that we agreed 
with MedPAC's assessment that hospitals include associated preparation 
and handling costs in their charges for the radiopharmaceutical. We 
strongly encouraged hospitals and the radiopharmaceutical community to 
assist us as we began developing a viable long-term prospective payment 
methodology for these products under OPPS.
    During the March 2006 meeting of the APC Panel, the Panel 
recommended that CMS work with stakeholders to continue to develop a 
methodology to pay for radiopharmaceuticals. While Federal law, 
including the Administrative Procedure Act (APA) and the Federal 
Advisory Committee Act (FACA), govern the forum by which we receive 
input of stakeholders, we have met with interested organizations to 
discuss the numerous complexities associated with developing 
radiopharmaceutical payments under the OPPS, and in the CY 2007 OPPS 
proposed rule, we again invited comment and feedback on how we may be 
able to improve on our methodology in future years. We note that we 
received relatively little feedback in response to our CY 2006 requests 
for comments on methodologies we could consider during the development 
of a methodology for radiopharmaceutical payments in the hospital 
outpatient setting in preparation for the CY 2007 proposed rule. We 
again specifically invite feedback on this issue and request comments 
for our consideration during the development of our proposal for CY 
2008 radiopharmaceutical payments.
    We considered a number of alternative methodologies for 
radiopharmaceutical payment policy under the OPPS in CY 2007. One of 
the options we considered for CY 2007 (71 FR 49587) was to package 
additional radiopharmaceuticals, either through increasing the 
packaging threshold for radiopharmaceuticals from a cost of $55 per day 
to a higher amount or through a policy that would package payments for 
all radiopharmaceuticals with payments for the services with which they 
are reported. All nuclear medicine procedures require the use of at 
least one radiopharmaceutical, and while many separately payable drugs 
may share the same drug administration HCPCS code, there are only a few 
radiopharmaceuticals that may be appropriately billed with the same 
nuclear medicine procedure. A policy to package additional 
radiopharmaceuticals would be consistent with OPPS packaging principles 
and would provide greater administrative simplicity for hospitals. We 
noted that while examining CY 2005 hospital claims data, we identified 
a significant number of nuclear medicine procedure claims that were 
missing HCPCS codes for the associated radiopharmaceutical. We believed 
that there could be two reasons for the presence of these claims in the 
data. One reason could be that the radiopharmaceutical used for the 
procedure was packaged under the OPPS and therefore would not be billed 
on the claim with a HCPCS code and an associated charge. The second 
reason could be that the hospitals may have incorporated the costs of 
the radiopharmaceutical into their charges for these nuclear medicine 
procedures. We did not propose this methodology for CY 2007 because we 
were concerned that payments for certain nuclear medicine procedures 
could potentially be less than the costs of some of the packaged 
radiopharmaceuticals, and that relatively expensive and high volume 
radiopharmaceuticals could become packaged. At the same time, we also 
note the GAO's comment in reference to the CY 2006 OPPS proposed rule 
that a methodology that includes packaging all radiopharmaceutical 
costs into the payments for the nuclear medicine procedures may result 
in payments that exceed hospitals' acquisition costs for certain 
radiopharmaceuticals as there may be more than one radiopharmaceutical 
that may be used for one particular procedure. We were also concerned 
that with such divergent outcomes, this payment policy could provoke a 
treatment decision that may not reflect the most clinically appropriate 
radiopharmaceutical for a particular nuclear medicine procedure. We 
also considered maintaining the CY 2006 policy of paying for 
radiopharmaceuticals at charges converted to cost.
    For CY 2007, our proposed methodology included a packaging 
threshold equal to that of other drugs and biologicals proposed for CY 
2007 and established prospective payment rates for separately payable 
radiopharmaceuticals using mean costs derived from the CY 2005 claims 
data, where the costs were determined using our standard methodology of 
applying hospital-specific departmental CCRs to radiopharmaceutical 
charges, defaulting to hospital-specific overall CCRs only if 
appropriate departmental CCRs were unavailable. This proposed payment 
methodology included both the acquisition and pharmacy handling costs 
of radiopharmaceuticals determined to be separately payable for CY 
2007. As we have noted previously, we agree with the MedPAC finding 
that hospitals include overhead costs in their charges for the 
associated radiopharmaceutical. We believe this methodology provides 
for an appropriate proxy for the average acquisition cost of the 
radiopharmaceutical along with its handling cost. We noted that this 
proposed methodology would be an appropriate long-term 
radiopharmaceutical payment policy that would allow us to consistently 
establish prospective OPPS payment rates for the acquisition and 
overhead costs of separately payable radiopharmaceuticals. We also 
proposed to update the packaging threshold consistent with the 
methodology discussed above.
    We noted in the proposed rule that the National HCPCS Panel 
implemented changes to many radiopharmaceutical codes and their 
descriptors effective January 1, 2006. In some instances, these changes 
were relatively minor; in

[[Page 68095]]

others, code descriptors changed from ``per unit'' to ``per study 
dose.'' The hospital claims data used for our proposed rule included 
radiopharmaceutical HCPCS codes that were in effect during CY 2005. 
Because there were significant changes in HCPCS code descriptors for 
several radiopharmaceuticals from CY 2005 to CY 2006, implementation of 
the proposed payment methodology for radiopharmaceuticals required us 
to propose a crosswalk to map the CY 2005 hospital claims data to 
updated CY 2006 codes that we expected to be in effect during CY 2007. 
Out of the 39 radiopharmaceutical HCPCS codes that we proposed to pay 
separately for in CY 2007, we were able to directly crosswalk the CY 
2005 cost data to 31 of these codes. The descriptors for the remaining 
eight codes changed from per unit of radioactivity in CY 2005 to new 
descriptors based on per study doses in CY 2006. Therefore, we proposed 
to use the per day costs based on the CY 2005 claims data as proxies 
for the per study dose costs for this subset of radiopharmaceutical 
HCPCS codes to be reported in CY 2007. (We refer readers to the CY 2007 
proposed rule for a more detailed description of our proposed crosswalk 
methodology.)
    We also noted in the proposed rule that there were three cases 
where two CY 2005 HCPCS codes were mapped to the same new CY 2006 HCPCS 
code that would be reported in CY 2007. These three CY 2006 HCPCS codes 
were A9550 (Tc99m gluceptate), A9553 (Cr51 chromate), and A9559 (Co57 
cyano). Because of the complicated nature of crosswalking the cost data 
for two predecessor HCPCS codes with different units in their 
descriptors to each of these new HCPCS codes, we proposed to crosswalk 
the cost data only from the predecessor HCPCS codes with the most 
claims volume in CY 2005 to each of these three HCPCS codes to be used 
for CY 2007 ratesetting purposes.
    Table 26 of the CY 2007 proposed rule (71 FR 49589) listed all of 
the CY 2007 separately payable radiopharmaceuticals and the predecessor 
HCPCS codes whose claims data were used to set the CY 2007 proposed 
payment rates and noted the crosswalk methodology used for the proposed 
rates.
(b) CY 2007 Final Radiopharmaceutical Payment Policy
    During the August 2006 meeting of the APC Panel, the Panel 
recommended that CMS continue the 1-year temporary policy of paying for 
radiopharmaceuticals at charges reduced to cost, using the overall 
hospital CCR. In addition, the Panel recommended that we consider using 
external data to evaluate the proposed payment rate for HCPCS code 
A9600 (Sr89 strontium) because of concerns about hospital miscoding of 
this radiopharmaceutical. We include our responses to these Panel 
recommendations in the discussion presented below.
    In addition to these Panel recommendations, we received many 
comments on our proposed payment methodology for radiopharmaceuticals 
in CY 2007.
    Comment: Several commenters supported our proposal to establish a 
prospective payment methodology for radiopharmaceuticals, but noted 
that, prior to the CY 2006 final rule with comment period, many 
hospitals were unaware that charges for the preparation and handling 
should be included in the charge for the associated 
radiopharmaceutical. Therefore, these commenters claimed that the CY 
2005 data used to establish proposed mean-based payment rates for CY 
2007 are inaccurate. In addition, commenters noted that several 
radiopharmaceutical HCPCS codes were updated in CY 2006 to standardize 
hospital coding for radiopharmaceuticals, and that CY 2005 data are 
unreliable because hospitals were not using the CY 2005 
radiopharmaceutical HCPCS codes uniformly. Other commenters noted that 
using a methodology that incorporates a departmental CCR is not 
appropriate for radiopharmaceuticals because the unique costs 
associated with radiopharmaceuticals are not properly accounted for 
within any department. For these reasons, commenters requested that CMS 
extend the temporary CY 2006 methodology of paying for separately 
payable radiopharmaceuticals at charges reduced to cost, where payment 
is determined using each hospital's overall CCR.
    Response: We understand the commenters' concerns regarding the data 
that are represented in the CY 2005 hospital claims, especially in 
light of the reports of confusion resulting from coding changes. We 
also acknowledge that the preparation and handling costs associated 
with administering radiopharmaceuticals are significant and should be 
fully captured in claims data used to establish prospective payments 
rates. At this time, we believe that there is sufficient reason to 
extend the temporary policy of paying for radiopharmaceuticals at 
charges reduced to cost for one additional year as the best proxy for 
radiopharmaceutical acquisition and overhead costs, consistent with the 
August 2006 recommendation of the APC Panel. Although we do believe 
that the costs unique to radiopharmaceuticals are recognized in several 
departmental cost-to-charge ratios, similar to the costs of many other 
items and services paid prospectively under the OPPS, consistent with 
the CY 2006 methodology, we will again calculate payment using each 
hospital's overall cost-to-charge ratio in CY 2007. As stated in the CY 
2006 final rule, we believe that using hospitals' overall CCRs to 
determine payments could result in an overstatement of 
radiopharmaceutical costs, which are likely reported in several cost 
centers such as diagnostic radiology that have lower CCRs than 
hospitals' overall CCRs. We note that it is still our intention to move 
toward a prospective payment methodology for radiopharmaceuticals in 
the OPPS, and that we generally employ departmental CCRs in setting 
payment rates for most items and services that are paid separately in 
the OPPS. We expect that for the CY 2008 OPPS update, hospitals will 
have adapted to the CY 2006 coding changes and responded to our 
instructions to include their charges for radiopharmaceutical handling 
in their charges for the radiopharmaceutical products. We anticipate, 
as do our commenters, that our CY 2006 claims data should be much more 
comprehensive and accurate in reflecting the full hospital costs for 
radiopharmaceutical products and their overhead. Because of the coding 
changes for CY 2006 to simplify radiopharmaceutical reporting, hospital 
data from that time should also reflect more consistent and correct 
coding because the HCPCS code units for reporting have been aligned 
with the clinical uses of the radiopharmaceuticals.
    Comment: One commenter suggested that CMS require ASP reporting for 
radioimmunotherapy radiopharmaceutical manufacturers. The commenter 
suggested that this data could be used in conjunction with a new HCPCS 
code for compounding services related to these radiopharmaceuticals. 
The commenter suggested that CMS assign the compounding HCPCS code to 
its own APC and set the payment rate between $2,000 and $3,000.
    Response: We appreciate these comments, but we do not believe that 
the complex issues relating to the collection of ASP data for 
radiopharmaceuticals, as discussed at length in the CY 2006 OPPS final 
rule with comment period (70 FR 68655),

[[Page 68096]]

have been resolved. Therefore, we believe that implementation of the 
collection of ASP data for these products remains premature. However, 
we will consider this comment during the development of future updates 
to the OPPS.
    Comment: One commenter requested that CMS instruct hospitals to 
include radiopharmaceutical handling costs in the charge for the 
associated nuclear medicine procedure.
    Response: We appreciate this comment. However, we believe that 
hospitals appropriately include these handling charges in their charges 
for drugs, biologicals, and radiopharmaceuticals. As such, we believe 
that these costs are already being captured through hospital charges 
for these items, which require preparation and handling for their 
administration. In addition, for hospitals that were not clear where 
these handling costs should be represented on a claim, we provided 
specific instructions in the CY 2006 final rule with comment period (70 
FR 68654). As we stated for CY 2006, and reiterate here for CY 2007, it 
is appropriate for hospitals to set charges for radiopharmaceuticals 
based on all costs associated with the acquisition, preparation, and 
handling of these products so that their payments under the OPPS can 
accurately reflect all of the actual costs associated with providing 
these products to hospital outpatients. If necessary, we believe that 
hospitals can appropriately adjust their charges for 
radiopharmaceuticals so that the calculated costs from applying 
hospitals' overall CCRs to radiopharmaceutical charges on claims 
properly reflect their actual costs. We do not believe it is 
appropriate to provide different instructions in this final rule with 
comment period, when we have many comments reflecting hospitals' 
efforts to respond to our CY 2006 instruction.
    We received a few comments that included specific suggestions for 
consideration during the future development of our proposed CY 2008 
radiopharmaceutical payment policy.
    Comment: Commenters suggested that CMS consider establishing a 
buffering mechanism when radiopharmaceuticals are transitioned to a 
prospective payment methodology; that we continue to use the overall 
hospital CCR to calculate costs, regardless of any future 
radiopharmaceutical payment methodology; that we consider a unique data 
trimming methodology for radiopharmaceuticals; and that we consider 
using the PPI as a basis for annual radiopharmaceutical payment 
updates.
    Response: We appreciate these comments, and we continue to 
encourage comments and suggestions on methodologies we may consider 
during the development of our CY 2008 proposed radiopharmaceutical 
payment policy.
    We also received several comments on the amount of pharmacy 
handling involved with compounding radiopharmaceuticals and preparing 
them for administration.
    Comment: Commenters proposed several methodologies for 
implementation in the OPPS to provide additional payment for 
radiopharmaceutical pharmacy handling costs. Additional payments are 
warranted, commenters noted, because radiopharmaceutical products 
require substantial preparation and handling prior to administration, 
and these services are unique to radiopharmaceuticals. In addition, 
commenters cite concerns regarding the effects of charge compression 
for these high cost items with substantially higher pharmacy handling 
costs (see section V.B.III.a.2. of this preamble for additional 
discussion on the issue of charge compression). Commenters included 
suggestions ranging from inflating proposed payment amounts to 
providing a fixed add-on payment amount.
    Response: As we noted in the CY 2006 final rule with comment period 
(70 FR 68654), we believe that hospitals have the ability to set 
charges for items properly so that charges converted to costs can 
appropriately account fully for their acquisition and overhead costs. 
As noted previously, commenters urged us to delay implementation of our 
proposed CY 2007 radiopharmaceutical payment methodology based on CY 
2005 mean unit costs calculated from hospital claims data because, they 
claimed, hospitals had only begun including associated overhead charges 
in response to our CY 2006 final rule, and these preparation and 
handling costs were not included in the CY 2005 claims data. As we are 
continuing our CY 2006 methodology of paying for radiopharmaceuticals 
at a hospital's charges for the radiopharmaceutical reduced to costs, 
based upon the hospital's overall CCR, we do not believe that an 
additional payment specific to overhead costs for radiopharmaceutical 
products is warranted at this time.
    Therefore, for CY 2007, we have concluded that our final payment 
methodology provides an acceptable proxy for the average acquisition 
cost of the radiopharmaceutical along with its handling cost. In 
addition, we believe that this final payment policy addresses the 
concerns of the APC Panel regarding HCPCS code A9500. Therefore, we are 
accepting this Panel recommendation and we have applied the packaging 
methodology for radiopharmaceuticals, as described above, and 
determined that HCPCS code A9500 will be separately payable in the OPPS 
in CY 2007. As such, payment will be at a hospital's charge for the 
radiopharmaceutical reduced to cost, using the overall hospital CCR. We 
again reiterate our intent to develop a suitable prospective payment 
methodology for radiopharmaceutical products paid under the OPPS in 
future years, beginning in CY 2008. We generally do not make payments 
under the OPPS for items and services at cost, particularly if we do 
not expect the costs of the services to vary substantially and 
unpredictably over time and if we have hospital claims data available. 
Paying for radiopharmaceuticals at cost provides hospitals with no 
incentive to supply radiopharmaceuticals in the most efficient manner. 
However, we are encouraged by recent reports of ongoing discussions 
within the radiopharmaceutical community to develop a viable, ongoing 
methodology for OPPS radiopharmaceutical ratesetting and recent 
meetings with members of the radiopharmaceutical community. We again 
specifically solicit comments on alternative methodologies and data 
sources that may be used to set radiopharmaceutical payment rates in 
the OPPS.
    While payments for drugs, biologicals and radiopharmaceuticals are 
taken into account when calculating budget neutrality, we proposed to 
make payments for drugs, biologicals, and radiopharmaceuticals without 
scaling these payment amounts. Section 1833(t)(14)(A)(iii)(I) requires 
that, beginning in CY 2006, we pay for a separately payable drug on the 
basis of ``the average acquisition cost of the drug.'' As we stated in 
the CY 2006 OPPS final rule with comment period (70 FR 42728), we 
believe that the best interpretation of the specific requirement that 
we pay for such drugs on the basis of average acquisition cost is that 
these payments themselves should not be adjusted as part of meeting the 
statutory budget neutrality requirement. If we were to apply a budget 
neutrality scalar to these payments, we would no longer be paying the 
average acquisition cost, but rather an adjusted average acquisition 
cost for separately payable drugs, biologicals, and 
radiopharmaceuticals. We believe that these amounts, without

[[Page 68097]]

a budget neutrality scalar applied, are the best proxies we have for 
the aggregate average acquisition and pharmacy overhead and handling 
costs of drugs, biologicals, and radiopharmaceuticals.
    Comment: A few commenters requested the implementation of edits 
similar to procedure to device edits that would require hospitals to 
include a radiopharmaceutical HCPCS code whenever a nuclear medicine 
procedure is billed.
    Response: We understand that coding accurately for the variety of 
services provided across a hospital setting can be challenging, as can 
be keeping current on changes to codes, modifiers and updated billing 
instructions. However, we do not believe that the appropriate solution 
to complex billing is the implementation of edits for a large number of 
services. As discussed above, during our review of claims for the CY 
2007 ratesetting process we identified a large number of claims without 
associated radiopharmaceuticals reported with nuclear medicine 
procedures. We believe that this may be due to hospitals using packaged 
radiopharmaceuticals, or because hospitals have already packaged the 
costs of the associated radiopharmaceutical into the cost of the 
nuclear medicine procedure. If this is the case, we do not believe that 
implementing procedure to radiopharmaceutical edits would be an 
appropriate mechanism for us to use in order to get additional data for 
radiopharmaceutical products. We do not mandate hospital charging 
practices for specific items, and implementing edits would be contrary 
to our general concept of encouraging hospitals to develop their 
charges, revenue centers and internal practices as they find 
appropriate. In addition, edits do not necessarily ensure quality data. 
Most importantly, we generally implement edits to ensure that high cost 
items with packaged payment are reported on appropriate claims, so that 
the procedural payment rates fully incorporate the costs of these items 
that are required for the procedures. We have no need to edit for the 
presence of radiopharmaceutical HCPCS codes on claims for nuclear 
medicine procedures when we will be paying separately in CY 2007 for 
all radiopharmaceuticals with per day costs greater than $55. 
Therefore, we are not accepting this commenter's proposal to implement 
procedure to radiopharmaceutical edits at this time.
    Comment: The manufacturer of a radiopharmaceutical product stated 
that HCPCS codes A9500 (Tc99m sestamibi) and A9502 (Tc99m tetrofosmin) 
are comparable in terms of safety and efficacy, and as such, there 
should be no difference in OPPS payment rates. It suggested that 
factors such as manufacturer rebates and incomplete hospital reporting 
may have contributed to inaccurate CY 2005 claims data. It suggested 
that the payment rates for these products be averaged and that the 
resulting rate be used for both products.
    Response: We believe the concerns expressed by this commenter are 
no longer applicable in light of the finalized payment methodology for 
radiopharmaceutical products in CY 2007 discussed above.
b. CY 2007 Payment for Nonpass-Through Drugs, Biologicals, and 
Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims 
Data
(1) Background
    Pub. L. 108-173 does not address the OPPS payment in CY 2005 and 
after for new drugs, biologicals, and radiopharmaceuticals that have 
assigned HCPCS codes, but that do not have a reference AWP or approval 
for payment as pass-through drugs or biologicals. Because there is no 
statutory provision that dictated payment for such drugs and 
biologicals in CY 2005, and because we had no hospital claims data to 
use in establishing a payment rate for them, we investigated several 
payment options for CY 2005 and discussed them in detail in the CY 2005 
OPPS final rule with comment period (69 FR 65797 through 65799).
    For CYs 2005 and 2006, we finalized our policy to provide separate 
payment for new drugs, biologicals, and radiopharmaceuticals with HCPCS 
codes, but which did not have pass-through status at a rate that was 
equivalent to the payment they received in the physician office 
setting, established in accordance with the ASP methodology.
    As discussed in the CY 2005 OPPS final rule with comment period (69 
FR 65797), and the CY 2006 OPPS final rule with comment period (70 FR 
68666), new drugs, biologicals, and radiopharmaceuticals may be 
expensive, and we are concerned that packaging these new items might 
jeopardize beneficiary access to them. In addition, we do not want to 
delay separate payment for these items solely because a pass-through 
application was not submitted. Therefore, we developed our proposed CY 
2007 payment methodologies for drugs, biologicals, and 
radiopharmaceuticals with HCPCS codes but without OPPS hospital claims 
data in line with our payment methodologies for newly established HCPCS 
codes that are granted pass-through status under the OPPS. (Section 
V.A. of this final rule with comment period provides additional details 
on our final policies for CY 2007 pass-through drugs, biologicals, and 
radiopharmaceuticals.) In Addendum B of the CY 2007 proposed rule, we 
assigned status indicator ``K'' to these new CY 2007 HCPCS codes for 
drug, biological, and radiopharmaceutical items without pass-through 
status.
(2) CY 2007 Proposed and Final Payment Policy for Radiopharmaceuticals 
With HCPCS Codes, But Without OPPS Hospital Claims Data
    In section V.B.3.a.(3) of this final rule with comment period, we 
discuss our proposed methodology to base payment rates for 
radiopharmaceuticals with CY 2005 hospital claims data at their mean 
costs for CY 2007. We also proposed to use WAC as a basis for 
ratesetting for new radiopharmaceuticals without hospital claims data 
that have been assigned HCPCS codes as of January 1, 2007, without 
regard to their pass-through status. If WAC data were unavailable, we 
proposed to use 95 percent of the most recent AWP, and to implement 
payment rate adjustments resulting from the quarterly update process 
accordingly.
    We received numerous comments on our proposed payment methodologies 
for radiopharmaceutical products, and one comment specific to HCPCS 
code A9567 (Technetium TC-99m aerosol).
    Comment: One commenter objected to our proposed packaged status for 
HCPCS code A9567. The commenter recommended that in the absence of data 
providing payment information, we assign HCPCS code A9567 status 
indicator ``H'' and provide payment in CY 2007 at charges reduced to 
cost.
    In addition, other commenters remarking on our proposed 
radiopharmaceutical policies requested that we continue our CY 2006 
payment methodology for separately payable radiopharmaceuticals (see 
section V.B.3.a.(3) of this preamble). That is, commenters requested 
that we continue to pay for radiopharmaceuticals at the hospital's 
charge for the radiopharmaceutical adjusted to the cost, using the 
hospital's overall CCR.
    Response: We believe it is appropriate to align our payment 
methodologies, whenever possible, within the OPPS. Therefore, for CY 
2007, we are finalizing our payment policy for nonpass-through 
radiopharmaceuticals without hospital claims data that have been 
assigned

[[Page 68098]]

HCPCS codes as of January 1, 2007, as follows: For CY 2007, hospitals 
will receive payment for nonpass-through radiopharmaceuticals without 
hospital claims data that have been assigned HCPCS codes as of January 
1, 2007, at the hospital's charge for the radiopharmaceutical adjusted 
to cost, using the hospital's overall cost-to-charge ratio. This 
methodology will provide payment for nonpass-through 
radiopharmaceuticals using the same payment methodology that we have 
finalized for pass-through radiopharmaceuticals in CY 2007, as 
discussed in section V.B.3.a.(3) of this final rule with comment 
period. As we discuss above, we are aware that due to the additional 
costs associated with new radiopharmaceuticals that a decision to 
package these items may affect beneficiary access. Therefore, when we 
are unable to determine the appropriate packaging status (as outlined 
in section V.B.2. of this preamble) for a radiopharmaceutical in CY 
2007 due to the lack of hospital claims data, we are finalizing a 
policy to provide payment for these items at the hospital's charge for 
the radiopharmaceutical adjusted to cost, using the hospital's overall 
CCR.
(3) CY 2007 Proposed and Final Payment Policy for Drugs and Biologicals 
With HCPCS Codes, But Without OPPS Hospital Claims Data
(a) New Drugs Without Hospital Claims Data
    For CY 2007, we proposed to continue payment for new drugs and 
biologicals with HCPCS codes as of January 1, 2007, but without pass-
through status, at a rate that is equivalent to the payment they would 
receive in the physician office setting, unless the drug or biological 
was also covered under the Part B drug CAP. If the drug or biological 
was covered under the Part B drug CAP, then we proposed to set the OPPS 
rate equal to the Part B drug CAP rate. If not, then we proposed to set 
the OPPS payment rate at a rate equal to the payment rate established 
in accordance with the ASP methodology described in the CY 2006 MPFS 
final rule, where payment will generally be equal to ASP+6 percent. 
Additional information on the ASP methodology can be found at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage.
    In the rare circumstance that a drug does not have a Part B drug 
CAP rate or data available for use for the ASP methodology, we proposed 
to make payment at 95 percent of the product's most recent AWP in order 
to be consistent with how we pay for new drugs, biologicals, and 
radiopharmaceuticals without HCPCS codes, as discussed in the CY 2006 
OPPS final rule with comment period (70 FR 68669). We noted in our 
proposal that it was our intent to adjust payment rates through the 
quarterly update process for items paid under a methodology other than 
ASP once ASP data became available and to make appropriate adjustments 
to the payment rates for new drugs and biologicals in the event that 
they become covered under the Part B drug CAP in the future.
    Table 26 below lists the new CY 2007 HCPCS codes for drugs, 
biologicals, and radiopharmaceuticals that were not available during 
development of the proposed rule. In addition, we note that these codes 
are included in Addendum B this final rule with comment period and are 
identified with comment indicator ``NI.''.

Table 26.--CY 2007 HCPCS Codes Without OPPS Claims Data and Without Pass-
                             Through Status
------------------------------------------------------------------------
   HCPCS code       Short description       CY 2007 SI      CY 2007 APC
------------------------------------------------------------------------
C9234...........  Inj, alglucosidase                  K             9234
                   alfa.
C9235...........  Injection,                          K             9235
                   panitumumab.
J0364...........  Apomorphine                         K             0766
                   hydrochloride.
J1324...........  Enfuvirtide injection               K             0767
J1562...........  Immune globulin                     K             0804
                   subcutaneous.
J2170...........  Mecasermin injection.               K             0805
J2315...........  Naltrexone, depot                   K             0759
                   form.
J8650...........  Nabilone oral........               K             0808
J9261...........  Nelarabine injection.               K             0825
------------------------------------------------------------------------

(b) Established Drugs Without Hospital Claims Data
    As we discussed in the CY 2007 proposed rule, there are several 
drugs, biologicals, and radiopharmaceuticals which are not new for CY 
2007, but for which we do not have CY 2005 hospital claims data. In 
order to determine the packaging status of these items for the CY 2007 
proposed rule, we estimated the per day cost of each item by 
multiplying the proposed payment rate of ASP+5 for each product by an 
estimated average number of units typically furnished to a patient 
during one administration in the hospital outpatient setting. We 
included our estimated average number of units in Table 27 of the CY 
2007 OPPS proposed rule (71 FR 49595).
    We proposed to use the same CY 2007 packaging methodology as was 
proposed for other drugs, biologicals, and radiopharmaceuticals. 
Specifically, we proposed that items with a per administration cost of 
less than or equal to $55 would be packaged and items with an estimated 
per administration cost greater than $55 would receive separate payment 
at a proposed rate of ASP+5 percent, using the ASP methodology, subject 
to adjustments as updates became available through the quarterly 
process. As we discussed in the proposed rule, we used the most recent 
data available at the time of the proposed rule to determine both the 
packaging status and payment rates for these drugs. We update these 
rates and reevaluate our proposed status indicators and payment rates 
for the final rule, as is the process for all other drugs, biologicals, 
and radiopharmaceuticals.
    We specifically requested comments on our proposed payment policies 
for drugs and biologicals with HCPCS codes but without hospital claims 
data that do not have pass-through status as of January 1, 2007.
    We received one comment specific to our packaging determination for 
HCPCS code J2805 (Sincalide injection) as a result of our proposal.
    Comment: One commenter objected to our proposed packaging 
determination for HCPCS code J2805. This commenter stated that in 
absence of data, codes should not automatically be packaged; rather, 
J2805 should be assigned status indicator ``K'' with a payment rate at 
ASP+6 percent for CY 2007.

[[Page 68099]]

    Response: As we noted in the CY 2007 proposed rule, we have an ASP-
based amount for HCPCS code J2805, however we do not have CY 2005 
hospital claims data available. Therefore, in absence of aggregate 
totals for the number of units and the number of days this code was 
billed on hospital claims in CY 2005, we estimated an average number of 
units that would be clinically appropriate for one administration of 
this drug to a typical hospital outpatient. Our estimate was included 
in Table 27 of the OPPS proposed rule (70 FR 49595). In order to 
determine the packaging status of this drug, we multiplied the ASP-
based payment rate by our estimated number of units per administration. 
We proposed to package HCPCS code J2805 because its cost per 
administration was below our proposed packaging threshold. The final 
packaging determination for CY 2007 for this code can be found in Table 
27.
    In addition to this code-specific comment, we believe that the 
general comments received regarding our proposed packaging methodology 
and the comments received regarding our proposed payment rate of ASP+5 
for nonpass-through drugs and biologicals also apply to this group of 
drugs with HCPCS codes but without CY 2005 hospital claims data and 
without pass-through status. (For a discussion of the comments and our 
responses to these issues, see sections V.B.2. and V.B.3. of this final 
rule with comment period.) For the reasons cited in sections V.B.2. and 
V.B.3. of this final rule with comment period, and because we believe 
it is appropriate to align our payment methodologies whenever possible 
within the OPPS, we are finalizing our policy for drugs and biologicals 
that have HCPCS codes but do not have pass-through status, and those 
that also do not have CY 2005 hospital claims data as follows: 
Packaging status will be determined using the threshold finalized in 
section V.B.2. of this final rule with comment period. That is, for CY 
2007, items with a per administration cost of less than or equal to $55 
would be packaged and items with an estimated per administration cost 
greater than $55 would receive separate payment. Estimating the per day 
costs for each item will be determined by multiplying the final payment 
rate (described in section V.B.3. of this final rule with comment 
period) for each product by the estimated average number of units 
typically furnished to a patient during one administration in the 
hospital outpatient setting as published in Table 27 of the proposed 
rule (71 FR 49595). For those drugs and biologicals that have been 
classified as separately payable using this final methodology, payment 
will be determined using the methodology finalized in section V.B.3. of 
this final rule with comment period. Therefore, drugs that have been 
identified as separately payable in CY 2007 will be paid under the ASP-
based methodology at a rate of ASP+6 percent, and will be subject to 
adjustments through the quarterly update process.
    Table 27 below shows our final determinations using the methodology 
finalized above for drugs and biologicals that do not have CY 2005 
hospital claims data and are not new for CY 2007. We note that since 
the time of the proposed rule, we have received claims data for two 
codes that were previously listed in Table 27 of the proposed rule. 
These codes are J0200 (Alatrofloxacin mesylate) and J0288 (Ampho b 
cholesteryl sulfate). Accordingly, these codes have been removed from 
the table and their packaging and payment rates determined under our 
final OPPS policy as noted in section V.B.1. of this final rule with 
comment period.
BILLING CODE 4120-01-P

[[Page 68100]]

[GRAPHIC] [TIFF OMITTED] TR24NO06.020

BILLING CODE 4120-01-C
    In addition, we note that HCPCS codes Q9945-Q9954 for low osmolar 
contrast material of various iodine concentrations were activated in 
the OPPS in CY 2006 and replaced several CY 2005 HCPCS A-codes that 
defined different sets of units in their descriptors. As we have no CY 
2005 hospital claims data for the Q-codes, we used the CY 2005 data 
from the HCPCS A-codes (HCPCS mean, number of units, and days) to 
determine the packaging status of the corresponding set of HCPCS Q-
codes for CY 2007. All of our estimated per-day administration rate 
determinations for the HCPCS A-codes were above the final OPPS CY 2007 
packaging threshold of $55, as discussed in section V.B.2. of this 
final rule with comment period. Therefore, we are determining that the 
corresponding set of CY 2007 HCPCS Q-codes will be paid separately in 
CY 2007. As there are ASP data available for these HCPCS Q-codes, they 
will be paid at the same rate as other separately payable drugs and 
biologicals in the OPPS for CY 2007, which in general will be equal to 
ASP+6 percent, subject to adjustments based on the quarterly update 
process. This final CY 2007 methodology for separately payable drugs 
and biologicals is discussed further in section V.B.3 of this final 
rule with comment period.
(4) CY 2007 Proposed and Final Payment Policy for Drugs, Biologicals, 
and Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital 
Claims Data and Without ASP-Related Data
    In addition to the drugs, biologicals, and radiopharmaceuticals 
without CY 2005 claims data identified in Table 27 of the proposed rule 
(71 FR 49595), we identified three HCPCS codes for which there were no 
available data to support the ASP methodology and no available hospital 
claims data from CY 2005. As we were unable to estimate the per 
administration cost of these three HCPCS codes (90393,Vaccina ig, im; 
90693, Typhoid vaccine, akd, sc; A9567, Technetium TC-99m aerosol), we 
proposed to package them in CY 2007. We specifically invited comments 
on our proposed policies for determining the per administration cost of 
the drugs, biologicals, and radiopharmaceuticals that are payable under 
the OPPS, but do not have any CY 2005 claims data.
    We received a few public comments concerning our proposed CY 2007 
policies for drugs, biologicals, and radiopharmaceuticals with HCPCS 
codes, but without OPPS hospital claims data and without ASP-related 
data.
    Comment: Commenters suggested that ASP pricing data are available 
for one or more of these items. Another commenter requested that we use 
alternative data sources, such as WAC or AWP, to determine the CY 2007 
packaging status of the three items listed above as ASP information is 
not available.
    Response: We appreciate these comments. During the data update 
process we perform between the CY

[[Page 68101]]

2007 proposed and final rules, we again queried for ASP-related data 
for these three items, including other sources such as WAC and AWP. 
Again, we were unsuccessful in identifying this information. However, 
in the course of our research for updated pricing data, we discovered 
that HCPCS code 90693 (Typhoid vaccine, akd, sc) is not available for 
purchase by hospitals. Therefore, we are assigning status indicator 
``B'' (Codes that are not recognized by OPPS when submitted on an 
outpatient hospital Part B bill type (12x and 13x)).
    After carefully considering the comments received, we are 
finalizing our CY 2007 proposed policy to package HCPCS code 90393 
(Vaccina ig, im), as we remain unable to determine pricing information 
for this item. Finally, HCPCS code A9567 (Technitium TC-99m aerosol) is 
a radiopharmaceutical, and as such, we are finalizing a policy to pay 
for this item in CY 2007 as we will pay for all new 
radiopharmaceuticals without claims data, regardless of pass-through 
status. Therefore, for CY 2007, we will pay for HCPCS code A9567 at the 
hospital's charge for the radiopharmaceutical adjusted to cost, using 
the hospital's overall CCR.
    In addition, HCPCS code J0190 (Inj biperiden lactate/5 mg) was 
packaged for CYs 2005 and 2006. As discussed in section V.B.2. of this 
final rule with comment period, to determine the CY 2007 final 
packaging status of drugs, biologicals, and radiopharmaceuticals we 
used ASP data from the first quarter of CY 2006 (reflected in payment 
rates in the physician office setting effective July 1, 2006), along 
with updated hospital claims data from CY 2005. Under this methodology, 
we determined that for CY 2007, HCPCS code J0190 will be separately 
payable. We note that for impact estimates and for purposes of 
publication of Addenda A and B of this final rule with comment period, 
we use payment rates for drugs, biologicals, and radiopharmaceuticals 
that are effective in the OPPS for October 2006. These rates are 
developed through the methodologies discussed in the CY 2006 final rule 
with comment period (70 FR 68631), and generally reflect ASP data from 
the second quarter of CY 2006, hospital claims data from CY 2004, or 
rates paid under the Part B drug CAP. This methodology essentially 
provides comparable payment rates across HCPCS codes at a specific 
point in time, and therefore enables consistency when calculating 
impact estimates. Under this methodology, we do not have ASP based data 
or CY 2004 claims-based mean unit cost data for HCPCS code J0190. 
Therefore, for purposes of impact estimates and for publication of 
Addenda A and B of this final rule with comment period, we have used 
the CY 2005 mean as it is the only pricing source available to us at 
this time.
    Also, based upon CY 2005 hospital claims mean unit cost data and 
the methodology described in section V.B.2. of this final rule with 
comment period, we have determined that HCPCS code A9566 (Tc99m 
fanolesomab) is separately payable in CY 2007. However, we do not have 
CY 2004 hospital claims data available for this code as its predecessor 
code, C1093, was not reported under the OPPS until January 1, 2005. 
Therefore, similar to HCPCS code J0190 described above, we are using 
the CY 2005 mean unit cost for this code for purposes of impact 
estimates. We note that there will be no payment rate information for 
this code included in Addenda A or B of this final rule with comment 
period because this code is a radiopharmaceutical and will be paid 
according to the methodology described in section V.B.3.a.(3) of the 
preamble of this final rule with comment period.

VI. Estimate of OPPS Transitional Pass-Through Spending in CY 2007 for 
Drugs, Biologicals, Radiopharmaceuticals, and Devices

A. Total Allowed Pass-Through Spending

    Section 1833(t)(6)(E) of the Act limits the total projected amount 
of transitional pass-through payments for drugs, biologicals, 
radiopharmaceuticals, and categories of devices for a given year to an 
``applicable percentage'' of projected total Medicare and beneficiary 
payments under the hospital OPPS. For a year before CY 2004, the 
applicable percentage was 2.5 percent; for CY 2004 and subsequent 
years, we specify the applicable percentage up to 2.0 percent.
    If we estimate before the beginning of the calendar year that the 
total amount of pass-through payments in that year would exceed the 
applicable percentage, section 1833(t)(6)(E)(iii) of the Act requires a 
uniform reduction in the amount of each of the transitional pass-
through payments made in that year to ensure that the limit is not 
exceeded. We make an estimate of pass-through spending to determine not 
only whether payments exceed the applicable percentage, but also to 
determine the appropriate reduction to the conversion factor for the 
projected level of pass-through spending in the following year.
    For devices, developing an estimate of pass-through spending in CY 
2007 entails estimating spending for two groups of items. The first 
group consists of those items for devices that were eligible for pass-
through payment in CY 2005 and/or CY 2006 and that would continue to be 
eligible for pass-through payment in CY 2007. The second group contains 
items that we know are newly eligible, or project would be newly 
eligible, for pass-through payment beginning in CY 2007.

B. Estimate of Pass-Through Spending for CY 2007

    As we proposed, in this final rule with comment period, we are 
setting the applicable percentage cap at 2.0 percent of the total OPPS 
projected payments for CY 2007. As we discuss in section IV.B. of this 
preamble, there is one device category receiving pass-through payment 
in CY 2006 that will continue for payment during CY 2007. In cases 
where we have relevant claims data for the procedures associated with a 
device category, we often project these data forward using inflation 
and utilization factors based on total growth in OPPS services as 
projected by CMS' Office of the Actuary (OACT) to estimate the upcoming 
year's pass-through spending for this first group of device categories. 
As we stated in the CY 2007 OPPS proposed rule (71 FR 49596), we may 
use an alternate growth factor for any specific device category based 
on our claims data or the device's clinical characteristics, or both. 
Based on our historical claims data for the procedures associated with 
the current device category continuing for pass-through payment into CY 
2007 and the device's clinical characteristics, we estimate pass-
through spending attributable to the first group (that is, one category 
for CY 2007) described above to be $44.0 million for CY 2007.
    To estimate CY 2007 pass-through spending for device categories in 
the second group, that is, items that we know at the time of 
development of this final rule with comment period would be newly 
eligible for pass-through payment in CY 2007 or contingent projections 
for new categories in the second through fourth quarters of CY 2007, we 
used the following approach. In general, as described for the first 
group of device categories above, if we have relevant claims data we 
may project these data forward using OACT inflation and utilization 
factors based on total growth in OPPS services, or we may use an 
alternate growth factor for any specific new device category based on 
our claims data or the device's clinical characteristics, or both. As 
we indicated in the proposed rule (71 FR 49596), we anticipated that 
any new

[[Page 68102]]

categories for January 1, 2007 would be determined after the 
publication of the proposed rule, but before publication of this final 
rule with comment period. For the two additional device categories that 
have now been approved for pass-through status as of January 1, 2007, 
we used price information and utilization estimates from manufacturers, 
because we did not have any relevant CY 2005 claims data upon which to 
base a spending estimate for CY 2007. To account for the contingency of 
new device categories that we project could become eligible for pass-
through status in the second, third, or fourth quarters of CY 2007, we 
used the general methodology as described above, while also considering 
the most recent OPPS experience in approving new pass-through device 
categories. Therefore, as indicated in our proposed rule (71 FR 49596), 
the estimate of pass-through spending in this CY 2007 OPPS final rule 
with comment period incorporates both CY 2007 estimates of pass-through 
spending for device categories made effective January 1, 2007, and 
estimates for those projected to be approved during subsequent quarters 
of CY 2007.
    With respect to CY 2007 pass-through spending for drugs and 
biologicals, as noted in the proposed rule (71 FR 49596) and explained 
in section V.A.3. of this final rule with comment period, the pass-
through payment amount for new drugs and biologicals that we determine 
to have pass-through status will equal zero. Therefore, in this final 
rule with comment period, our estimate of pass-through spending for 
drugs and biologicals with pass-through status in CY 2007 equals zero.
    In the CY 2005 OPPS final rule with comment period (69 FR 65810), 
we indicated that we are accepting pass-through applications for new 
radiopharmaceuticals that are assigned a HCPCS code on or after January 
1, 2005. (Prior to this date, radiopharmaceuticals were not included in 
the category of drugs paid under the OPPS, and therefore, were not 
eligible for pass-through status.) There are no radiopharmaceuticals 
that were eligible for pass-through payment in CY 2005 or at the time 
of publication of this final rule with comment period in CY 2006. In 
addition, we have no information identifying new radiopharmaceuticals 
to which a HCPCS code might be assigned on or after January 1, 2007, 
for which pass-through payment status would be sought. We also have no 
data regarding payment for new radiopharmaceuticals with pass-through 
status under the methodology that we specified in the CY 2005 OPPS 
final rule with comment period. However, we do not believe that pass-
through spending for new radiopharmaceuticals in CY 2007 will be 
significant enough to materially affect our estimate of total pass-
through spending in CY 2007. Therefore, we are not including 
radiopharmaceuticals in our final estimate of pass-through spending for 
CY 2007. We discuss the methodology for determining the CY 2007 payment 
amount for radiopharmaceuticals with pass-through status in section 
V.B.3.b. of this preamble.
    In accordance with the methodology described above, we estimate 
that total pass-through spending for both device categories that are 
continuing into CY 2007 and those that first become eligible for pass-
through status during CY 2007 will equal approximately $65.6 million, 
which represents 0.21 percent of total OPPS projected payments for CY 
2007. This figure includes an estimate for the current device category 
continuing into CY 2007, which equals approximately $44.0 million, in 
addition to projections for both categories that were approved after 
publication of the OPPS proposed rule effective January 1, 2007, and 
discussed in section IV.B. of the preamble of this final rule with 
comment period, and new categories that may become eligible during the 
subsequent quarters of CY 2007.

  Table 28.--Estimate of CY 2007 Transitional Pass-Through Spending for
          Current Pass-Through Category Continuing into CY 2007
------------------------------------------------------------------------
                                                              CY 2007
                         Existing pass-       CY 2007     estimated pass-
    HCPCS       APC      through device      estimated        through
                            category        utilization      payments
------------------------------------------------------------------------
C1820.......     1820  Generator,                  5,483     $43,974,519
                        neurostimulator
                        (implantable),
                        with
                        rechargeable
                        battery and
                        charging system.
------------------------------------------------------------------------

    Because we estimate that pass-through spending in CY 2007 will not 
amount to 2.0 percent of total projected OPPS CY 2007 spending, we will 
return 1.79 percent of the pass-through pool to adjust the conversion 
factor, as we discuss in section II.C. of this preamble.
    Accordingly, we are finalizing our proposed methodology for 
estimating CY 2007 OPPS pass-through spending for drugs, biologicals, 
and categories of devices. Our final total pass-through estimate for CY 
2007 is $65.6 million.

VII. Brachytherapy Source Payment Changes

A. Background

    Section 1833(t)(2)(H) of the Act, as added by section 621(b)(2)(C) 
of Pub. L. 108-173, mandated the creation of separate groups of covered 
OPD services that classify brachytherapy devices separately from other 
services or groups of services. The additional groups must reflect the 
number, isotope, and radioactive intensity of the devices of 
brachytherapy furnished, including separate groups for palladium-103 
and iodine-125 devices. In accordance with this provision, since CY 
2004 we have established four new brachytherapy source codes and 
descriptors.
    Section 1833(t)(16)(C) of the Act, as added by section 621(b)(1) of 
Pub. L. 108-173, established payment for devices of brachytherapy 
consisting of a seed or seeds (or radioactive source) based on a 
hospital's charges for the service, adjusted to cost. The period of 
payment under this provision is for brachytherapy sources furnished 
from January 1, 2004, through December 31, 2006. Under section 
1833(t)(16)(C) of the Act, charges for the brachytherapy devices may 
not be used in determining any outlier payments under the OPPS for that 
period of payment. Consistent with our practice under the OPPS to 
exclude items paid at cost from budget neutrality consideration, these 
items have been excluded from budget neutrality for that time period as 
well.
    In the OPPS interim final rule with comment period published on 
January 6, 2004 (69 FR 827), we implemented sections 621(b)(1) and 
(b)(2)(C) of Pub. L. 108-173. In that rule, we stated that we would pay 
for the brachytherapy sources listed in Table 4 of the interim final 
rule with comment period (69 FR 828) on a cost basis, as required by 
the statute. Since January 1, 2004, we have used status indicator ``H'' 
to denote nonpass-through brachytherapy sources paid on a cost basis, a 
policy that we

[[Page 68103]]

finalized in the CY 2005 final rule with comment period (69 FR 65838).
    Furthermore, we adopted a standard policy for brachytherapy code 
descriptors, beginning January 1, 2005. We included ``per source'' in 
the HCPCS code descriptors for all those brachytherapy source 
descriptors for which units of payment were not already delineated.

B. Government Accountability Office's Final Report on Devices of 
Brachytherapy

    Section 621(b)(3) of Pub. L. 108-173 required the Government 
Accountability Office (GAO) to conduct a study to determine appropriate 
payment amounts for devices of brachytherapy, and to submit a report on 
its study to the Congress and the Secretary, including recommendations. 
This report was due to Congress and to the Secretary no later than 
January 1, 2005. The GAO's final report, ``Medicare Outpatient 
Payments: Rates for Certain Radioactive Sources Used in Brachytherapy 
Could Be Set Prospectively'' (GAO-06-635), which was published on July 
24, 2006, was not available in time for review and discussion in the CY 
2007 OPPS proposed rule. Therefore, we are summarizing and discussing 
the report's findings and recommendations in this final rule with 
comment period. The GAO report principally recommends that we use OPPS 
historical claims data to determine prospective payment rates for two 
of the most frequently used brachytherapy sources, iodine-125 and 
palladium-103, and also recommends that we consider using claims data 
for the third source studied, high dose rate (HDR) iridium-192. During 
the GAO hospital purchase price study period, separate device codes 
were not available to specifically distinguish high activity and low 
activity iodine and palladium sources. Therefore, in addition to 
establishing prospective payment rates for iodine-125 (C1718) and 
palladium-103 (C1720) based on claims data, the GAO states that it 
expects CMS to have data available to set prospective payment rates for 
high activity iodine-125 (C2634) and palladium-103 (C2635) sources in 
CY 2007 as well. These two codes were created in CY 2005 as a result of 
the Medicare Modernization Act (MMA) requirement that the OPPS 
establish brachytherapy device payments that account for the 
radioactive intensity of the sources.
    The GAO studied 3 of the 12 specific sources currently paid 
separately under the OPPS: palladium-103, iodine-125, and HDR iridium-
192. The GAO conducted a survey of purchase prices paid by 121 
hospitals, from July 1, 2003, through June 30, 2004. These hospitals 
were carefully selected to be representative of all hospitals providing 
these sources in CY 2002. The GAO used a regression model to identify 
stratification factors that would maximize the difference in mean 
purchase price among strata of the sample. It grouped hospitals into 
major teaching hospitals, nonmajor teaching hospitals, urban 
nonteaching hospitals, and rural nonteaching hospitals. The GAO placed 
small hospitals into a separate stratum to ensure that they were 
appropriately represented.
    For iodine and palladium sources, the survey requested reporting of 
the name of the manufacturer, the number of sources, the price per 
source, and certain characteristics of the sources purchased, such as 
radioactivity level and configuration. For iridium, it requested 
reporting of the name of the manufacturer, the number of treatments 
delivered, the source price, and its rebate eligibility. The GAO survey 
had an overall response rate of 51 percent, and the GAO was able to 
calculate the mean and median purchase prices for iodine and palladium. 
Few hospitals reported receiving rebates.
    To estimate the hospitals' mean and median purchase prices for 
iodine and palladium sources, the sample hospitals' purchase price data 
were weighted to make them representative of the sample frame of 
hospitals from which the sample was drawn. The GAO used standard 
statistical trimming principles, which resulted in the exclusion of 
only 2 percent of the reported purchase prices of iodine and exclusion 
of none of the reported purchase prices of palladium. It estimated the 
mean price per source as $29.54 (median $25.37) for iodine from data 
submitted by 52 hospitals and $45.35 (median $45.46) for palladium from 
data submitted by 40 hospitals, with very low price variability across 
hospitals. Specifically, the coefficients of variation for the mean 
estimates were 1.59 percent for the iodine purchase price data and 0.68 
percent for the palladium purchase price data. This shows a remarkably 
low degree of variability within the data for the purchase prices of 
iodine and palladium brachytherapy sources during the survey period.
    The GAO found this price information to be reasonably consistent 
with cost data calculated from historical OPPS claims for the sources. 
It speculated that, to the extent that price variation in the survey 
data existed across either palladium or iodine sources, this variation 
could be attributed to differential pricing by source characteristics, 
such as configuration or radioactivity level. While the GAO stated that 
its survey data were insufficient to reliably identify any price 
differences by source characteristics, it concluded that any price 
variation should be reflected in its survey data because hospitals were 
to report all their purchases during the survey period. The GAO 
indicated that its results could be appropriately generalized to the 
approximately 950 hospitals providing these sources in the outpatient 
department that met the sampling criteria, and stated that the sampling 
frame contained 98 percent of the hospitals submitting OPPS claims for 
the three brachytherapy sources in CY 2002.
    Only 19 hospitals responded to the survey with iridium information, 
but 11 did not provide the number of treatments and/or reported 
questionable source prices, resulting in the GAO's inability to 
estimate the cost per treatment in these cases. For the other eight 
hospitals, there were also data inconsistencies. Because the GAO could 
not establish a unit cost for iridium, it could not assess if the unit 
cost of iridium varied substantially and unpredictably over time in a 
way that would make establishing a prospective payment rate 
inappropriate.
    The GAO report concluded that CMS could set prospective payment 
rates based on claims data for iodine and palladium sources, because 
the sources' unit costs are generally stable, both sources have 
identifiable unit costs that do not vary substantially and 
unpredictably over time, and reasonably accurate claims data are 
available. On the other hand, the GAO report explained that it was not 
able to determine a suitable methodology for paying separately for HDR 
iridium. The report noted that iridium is reused across multiple 
patients, making its unit cost more difficult to determine. However, 
the report also indicated that CMS has outpatient claims data from all 
hospitals that have used iridium and that in order to identify a 
suitable methodology for separate payment, CMS would be able to use 
these data to establish an average cost and evaluate whether that cost 
varies substantially and unpredictably.

C. Payments for Brachytherapy Sources in CY 2007

    As indicated above, the provision to pay for brachytherapy sources 
at charges reduced to cost expires after December 31, 2006, in 
accordance with section 1833(t)(16)(C) of the Act. However, under 
section 1833(t)(2)(H) of the Act,

[[Page 68104]]

CMS is still required to create APC groupings that classify devices of 
brachytherapy separately from other services or groups of services in a 
manner reflecting the number, isotope, and radioactive intensity of the 
devices of brachytherapy furnished.
    In the CY 2007 OPPS proposed rule, we proposed to pay separately 
for each of the sources listed in Table 29 of that rule (71 FR 49597) 
on a prospective basis for CY 2007, with payment rates to be determined 
using the CY 2005 claims-based median unit cost per source for each 
brachytherapy device (with the exception of Ytterbium-169, as discussed 
below). Consistent with our policy regarding APC payments made on a 
prospective basis, we proposed that the cost of brachytherapy sources 
be subject to the outlier provisions of section 1833(t)(5) of the Act. 
As indicated in section II.A.2. of this preamble, for CY 2007 we 
proposed specific payment rates for brachytherapy sources, which would 
be subject to scaling for budget neutrality.
    Table 29 of the proposed rule included a complete listing of the 
HCPCS codes, long descriptors, APC assignments, APC titles, and status 
indicators that we currently use for brachytherapy sources paid under 
the OPPS in CY 2006, and that we proposed to use for CY 2007. The 
brachytherapy sources and related information in Table 29 were the same 
sources and information as those listed in Table 28 of the OPPS CY 2006 
final rule with comment period (70 FR 68676). No additional 
brachytherapy sources have been added since the CY 2006 final rule with 
comment period.
    As indicated in the CY 2007 OPPS proposed rule (71 FR 49597), we 
believed there were a number of advantages to this proposed payment 
method. The OPPS is a prospective payment system under which payment 
rates are generally established based on median costs from historical 
hospital claims. Under our proposal, brachytherapy sources would be 
paid using the same basic median cost methodology as the overall OPPS. 
We believed that the payment of sources based on this approach would 
thus be an integral part of the OPPS, rather than a separate cost-based 
payment methodology within the OPPS. In addition, we proposed this 
option because we believed that consistent and predictable 
prospectively established payment rates under the OPPS for 
brachytherapy sources would be appropriate. We doubted that the 
hospital resource costs associated with specific brachytherapy sources 
would vary greatly across hospitals or clinical conditions under 
treatment, other than through differences in the numbers of sources 
utilized, which would be accounted for in our proposed per source 
payment methodology. We also believed that the proposed prospective 
payment methodology would promote efficiency in the provision of 
sources, while continuing to provide payments that reflect the wide 
clinical variation in the use of brachytherapy sources related to many 
factors, including tumor type and stage, patient anatomy, and planned 
brachytherapy dose. In addition, under the proposal we would continue 
to pay for brachytherapy sources separately using the same C-codes and 
descriptors that hospitals have reported for the last several years.
    We received numerous comments regarding our CY 2007 proposed 
payment methodology for brachytherapy sources.
    Comment: A number of commenters objected to CMS' proposal to set 
prospective payment rates based on median unit costs of sources because 
they believed that there was no valid, useful source of data for 
brachytherapy sources upon which to base prospective payment rates for 
CY 2007. The commenters stated that the GAO survey data were 
fundamentally flawed and should be disregarded by CMS, and that CMS' 
claims data also did not reflect the true hospital costs of 
brachytherapy sources. Specifically with regard to the GAO survey, they 
believed that the data collected by the GAO were outdated, and that the 
survey response rate was inadequate as the basis for conclusions 
regarding the costs of sources. They stated that the GAO survey failed 
to provide data sufficient for analyses by source configuration 
(specifically, loose sources versus stranded sources) and type of 
hospital (specifically, rural versus urban), both of which they 
believed should be taken into account in setting prospective payment 
rates for brachytherapy sources.
    The commenters also stated that the CMS claims data were not valid 
because they were not available by source configuration (that is, loose 
sources versus stranded sources), which commenters viewed as an 
important distinction with respect to clinically meaningful 
characteristics and costs. They observed that the CMS cost data showed 
significant variation in unit costs across hospitals, and that the 
number of claims containing source charges was inadequate. They 
objected to reliance on CMS' cost data because they stated that two-
thirds of the source APCs have fewer than 50 hospitals reporting cost 
data for sources. They concluded that the CMS data must be erroneous, 
because it showed the costs of low activity iodine and palladium 
sources to be higher than the costs of high activity sources of iodine 
and palladium, a result that contradicted their expectations. The 
commenters believed that the use of median costs was not valid because 
median costs can result in a single claim or hospital being the 
determinant of the median cost. Therefore, they concluded that basing 
brachytherapy source payment on a median cost did not fully represent 
the costs of all hospitals.
    Response: In contrast to the commenters' opinions, we believe that 
both the GAO survey information and CMS' claims data provide sufficient 
valid information on which to base prospectively established payment 
rates for brachytherapy sources. The findings of the GAO survey and 
CMS' claims data are sufficiently similar and stable to justify the use 
of claims data in setting prospective payment rates for brachytherapy 
sources. We do not view the delay in the publication of the GAO report 
as causing its contents to be outdated. In fact, the law that required 
the survey was passed on December 23, 2003. Instead of choosing to 
survey hospital costs only from CY 2003 or before, GAO, after seeking 
the views of stakeholders, chose to survey for the period, July 1, 
2003, through June 30, 2004, in order to acquire the most current 
information available at the time that the survey was performed.
    We found the GAO survey to provide credible information based on a 
stratified sample of all relevant categories of hospitals furnishing 
brachytherapy sources. We noted that there was remarkably little 
variation within the cost data elements for the iodine and palladium 
sources, the two most commonly billed sources under the OPPS. The GAO 
survey was performed using standard survey techniques, and the 
statistics were calculated using standard statistical methods. The 
coefficients of variation demonstrated a remarkable amount of stability 
for the data which were gathered from a wide range of provider types. 
We agree with the GAO that the response to the survey, while not 
sufficiently robust to provide information by source configuration or 
other characteristics of sources, is sufficient to provide a valid 
measure of the purchase price for iodine and palladium sources. We do 
not believe that the information from the survey was insufficient to 
yield valid estimates of hospital costs. Moreover, the median costs 
provided by the GAO survey are remarkably consistent with the median 
costs derived from Medicare claims data

[[Page 68105]]

over the years as discussed below and shown in Table 29.
    The GAO report recommended that we use OPPS claims data to 
determine prospective payment rates for two of the most frequently 
utilized brachytherapy sources, iodine-125 and palladium-103. In 
addition, the GAO report stated that it was unable to determine a 
suitable methodology for paying separately for HDR iridium because the 
survey provided insufficient data to identify and evaluate iridium's 
average unit cost across hospitals. However, the GAO observed that CMS 
has historical outpatient claims data from all hospitals that have 
provided iridium sources. The GAO concluded that CMS should be able to 
use its data to establish an average unit cost for HDR iridium, which 
could then be evaluated for suitability as the basis for separate 
payment, specifically considering whether the source cost varies 
substantially and unpredictably.
    We do not believe the absence of data by configuration or type of 
hospital is relevant to the validity of the median costs of iodine and 
palladium sources that resulted from the survey. We discuss the issue 
of changes in source configuration in more detail below in the context 
of the CMS data. With respect to the absence of statistics by type of 
facility, we believe that the consistency between the GAO survey 
purchase prices and the CMS data (which are based on billing by all 
hospitals regardless of type) shows that the lack of response by rural 
hospitals to the GAO survey is not meaningful.
    We believe that there are sufficient and valid CMS claims data upon 
which to base prospective payment rates per source for each of the 
brachytherapy sources with available historical claims information. 
Sources of brachytherapy have been separately paid for virtually all of 
the history of the OPPS, with packaging of iodine and palladium sources 
only for prostate brachytherapy in CY 2003, when there was separate 
payment in that year for these sources for other uses. Moreover, before 
CY 2003 the sources were paid separately under the transitional pass-
through payment methodology as pass-through devices. Therefore, 
hospitals have now had 6 years of experience in billing the sources 
separately to receive payment for these relatively costly items. Due to 
their pass-through payments in CYs 2000 through 2002 and payments at 
charges reduced to costs for CYs 2004 through 2006, hospitals have 
historically had a strong incentive to bill for sources at charges that 
reflected the costs of the sources. Therefore, to the extent that the 
commenters believed that our data show rank order anomalies or 
inadequate charges or wide variations in charges, we must assume that 
the charges reflect the hospitals' perceptions of the relative costs of 
the sources, and hospitals alone choose the charges they submit to 
Medicare and to all other payers.
    With regard to the use of the median cost, we note that the use of 
median costs for sources of brachytherapy is identical to the basis of 
payments for all services paid under the OPPS, other than drugs and 
biologicals, pass-through devices, and some new technology services. 
The nature of basing weights on median costs is that the volume of 
services, by definition, controls the median cost because the median is 
the 50th percentile of the array of data. However, use of the median 
cost also simultaneously eliminates the influence of not only the 
highest but also the lowest values in the array. Moreover, as the OPPS 
is a budget neutral relative weight system, it is the relativity of the 
medians that is important and not the specific median itself. 
Therefore, it is important that the same measure of central tendency 
(in this case the median cost) be used to establish the weights for all 
OPPS services to which the conversion factor applies to calculate their 
payment rates.
    We also do not consider the absence of data specific to loose 
versus stranded brachytherapy sources to be relevant to the calculation 
of sources' median costs. We have, as the law specified, established 
source codes for purposes of separate payments that take into account 
the number, isotope, and radioactive intensity of the sources. As with 
other medical devices, there will always be incremental improvements in 
the technology. We consider the configuration of sources as loose or 
stranded to be an incremental change, whose potential differential 
costs would be reflected in source cost data as the change penetrates 
the market for the product. As such, the impact of differing 
configurations would become apparent in hospital claims data over time 
as a matter of natural course. Based on the historical technological 
evolution in stranded brachytherapy sources, we expect that our CY 2005 
median costs for sources already reflect their partial market 
penetration, as indicated in the comments and discussed later in this 
section. Moreover, we do not agree that special action is necessary to 
prevent disincentives to the use of improved products. We believe that 
hospitals and physicians balance the additional benefit to patients of 
improved products with the additional costs, if any, of those products. 
One of the functions of a prospective payment system is to encourage 
wise purchasing while simultaneously making appropriate payments for 
the services being furnished. We believe that payments based on the 
median unit costs of brachytherapy sources support this goal.
    Our review of the GAO findings and examination of OPPS claims data 
support use of the median costs from CMS'' claims data as the basis for 
the CY 2007 payment rates for brachytherapy sources. In Table 29 below, 
we have summarized available historical OPPS information for the iodine 
and palladium sources studied by the GAO, in the context of our CY 2007 
final rule median unit costs.

  Table 29.--Median Costs, Payment Rates, and GAO Study Findings for Iodine and Palladium Brachytherapy Sources
----------------------------------------------------------------------------------------------------------------
                                                                                   Estimated CY
                                          CY 2003      CY 2004      GAO survey      2006 median    CY 2007 final
                Source                    payment      proposed   median price @  payment            unit cost
----------------------------------------------------------------------------------------------------------------
Iodine-125............................       $31.33       $36.35          $25.37          $32.63          $36.12
Palladium-103.........................        43.96        44.00           45.46           48.92           48.53
----------------------------------------------------------------------------------------------------------------
* Based on median from CY 2001 claims.
** Based on median from CY 2002 claims.
@ Purchase price between July 2003 and June 2004.
 Based on charges reduced to cost method.


[[Page 68106]]

    While the CY 2007 final rule median costs are established as median 
unit costs calculated using the standard OPPS methodology of applying 
specific departmental CCRs, if available, to claims' charges, and 
defaulting to overall hospital CCRs only if departmental CCRs are 
unavailable, estimated CY 2006 payments are calculated according to the 
cost-based payment methodology in effect during CY 2006, which reduces 
charges to costs using overall hospital-specific CCRs. The table shows 
great consistency of OPPS claims data for these sources over the past 5 
years, yielding reasonably stable median costs, with their associated 
payment rates, as either proposed or finalized over time. The CY 2007 
final rule median costs for iodine, although based on claims for 
services provided approximately 1 to 2 years later than the dates of 
service for the survey data collected by the GAO regarding hospital 
purchase prices, are significantly higher than the median GAO purchase 
prices. For palladium, the final rule median cost is about 8 percent 
higher. On average, the CY 2007 median cost for iodine sources would be 
about 11 percent greater than the median payment under the CY 2006 
cost-based methodology, while for palladium sources it would be about 
the same. Thus, we are relatively confident that the CY 2007 final rule 
brachytherapy source median unit costs from CY 2005 claims that are the 
basis of the CY 2007 payment rates for sources are reasonably accurate 
and should ensure continued access by Medicare beneficiaries to 
brachytherapy services delivered with these commonly used iodine and 
palladium sources.
    We also found that, for the eight other brachytherapy sources for 
which we have hospital claims data from CY 2005, hospital costs for 
these sources do not vary more significantly than for the two sources 
previously discussed. Of these eight sources, gold-198 (C1716), non-HDR 
iridium-192 (C1719), and yttrium-90 (C2616) were established sources in 
CY 2003, the only previous year where the OPPS provided separate 
payments for some brachytherapy sources (other than pass-through 
payments in years prior to CY 2003). Their CY 2003 payment rates were 
$22.74, $27.29, and $6,485.37, respectively, relatively consistent with 
our CY 2007 final rule median costs of $36.61, $23.01, and $10,525.13, 
respectively, based on CY 2005 claims data. Iodine-125 brachytherapy 
solution (C2632) was paid in CY 2003 as a pass-through device, without 
a prospective payment rate. In CY 2003, the OPPS did not pay for 
cesium-131, ytterbium-169, and linear palladium-102, and had not yet 
distinguished high activity iodine-125 and palladium-103 sources.
    While we have relatively low CY 2005 days and units for several of 
these 8 sources, we have at least 320 units for each one. We estimate 
that half of these devices would experience an increase in payment of 4 
percent to 38 percent under the CY 2007 final rule methodology compared 
with their median payments under the CY 2006 cost-based methodology, 
while the others would experience decreases of 17 percent to 38 
percent. This variation reflects the numerous different departmental 
CCRs that are used to calculate costs for brachytherapy from the 
relatively small number of hospitals reporting charges for many of the 
sources, in comparison with their overall hospital CCRs. We can 
identify no specific problems with the data for these eight sources 
that would cause us to question the accuracy of the CY 2007 final rule 
payment rates based on the sources' median costs from CY 2005 claims 
data. Therefore, we believe that the median cost per source from CY 
2005 Medicare claims data provides a sufficient and valid basis to 
establish a prospective payment rate for each brachytherapy source with 
available CY 2005 claims data.
    Comment: A few commenters questioned our median costs published in 
the CY 2007 OPPS proposed rule for high activity iodine-125 source 
(C2634), pointing out the proposed payment rate for C2634 was $25.68, 
which is lower than the proposed payment rate for the iodine-125 source 
(C1718) at $35.42. One commenter indicated that this reflected a rank 
order anomaly in proposed payments for high activity brachytherapy 
sources, and added that high activity iodine-125 sources always cost 
more, and typically may be many times more expensive than the 
corresponding low activity sources. The commenter stated that this 
error in the payment for high activity sources must be corrected for 
the sources to be clinically available.
    Response: While the median cost of C2634 for this CY 2007 final 
rule with comment period, $32.49, is still lower than the median cost 
for C1718, at $36.12, the median cost for the high activity source is 
somewhat higher than proposed, and the gap between the median costs of 
the two sources has narrowed. The commenters did not provide data 
supporting their assertion that the cost of the high activity iodine-
125 source is typically many times greater than the cost of the 
traditional low activity iodine-125 source. We acknowledge that the 
relatively low volume of claims from a small number of hospitals for 
the high activity iodine source from CY 2005 may contribute to the 
variability in its median cost, but we see no reason to believe that 
its median cost would not be appropriately reflective of the costs to 
hospitals providing the source in CY 2005. The GAO also noted that it 
expected us to have claims data from CY 2005 that could be used to 
establish a prospective payment rate for the high activity iodine-25 
source.
    Comment: Two commenters objected to our proposal to pay for sources 
of brachytherapy based on the median cost and asked that CMS set a 
prospective per source payment rate base on the mean cost derived from 
our claims data. One commenter believed that sources of brachytherapy 
should be paid based on prospectively set mean costs because they 
should be paid on the same basis as radiopharmaceuticals, for which we 
proposed to pay based on mean cost because both brachytherapy sources 
and radiopharmaceuticals contain radioactive material, are regulated by 
the Nuclear Regulatory Commission, and have the same storage, handling, 
and disposal requirements.
    Response: We disagree that sources of brachytherapy should be paid 
identically to radiopharmaceuticals. Radiopharmaceuticals are defined 
by MMA as drugs and drugs are, by law, paid based on hospital average 
acquisition cost. Sources of brachytherapy are not required by law to 
be paid at average acquisition cost, and therefore we are setting the 
CY 2007 payment for these items based on median costs derived from our 
claims data, like most other OPPS services that are not drugs. We refer 
readers to the discussion below, in response to a comment, concerning 
our policy for payment of the handling and storage costs of 
brachytherapy sources.
    Comment: A few commenters asserted that CMS did not provide an 
estimate of the effect on payments for brachytherapy sources due to the 
proposed change from a payment methodology of charges reduced to cost 
to a median cost methodology. They recommended that CMS evaluate the 
impact of any proposed changes in payment methodologies for 
brachytherapy sources and radiopharmaceuticals.
    Response: In fact, we did consider the impact of the proposed 
brachytherapy source payment methodology and alternatives as discussed 
in section XXVII.B.1.b. of the CY 2007 proposed rule (71 FR 49681).

[[Page 68107]]

    Comment: One commenter disagreed with our proposal that the cost of 
brachytherapy sources should be subject to the outlier provisions of 
the OPPS, indicating that historically brachytherapy sources have not 
been subject to additional outlier payments. The commenter also stated 
that services assigned to status indicator ``K'' status have not been 
eligible for outlier payments for the past 2 years. The commenter 
indicated that these types of changes are burdensome on hospitals and 
believed that brachytherapy sources should be excluded from outlier 
calculations, like separately paid drugs and devices receiving pass-
through payments.
    Response: Unlike separately paid drugs and devices eligible for 
pass-through payments, our proposal for brachytherapy sources is to pay 
for them based on median costs, which the commenter supports. 
Therefore, we are merely making our policy for brachytherapy sources 
consistent with our policy regarding other APC payments based on median 
costs, including that they be subject to the outlier provisions of 
section 1833(t)(5) of the Act. We are finalizing our proposal to make 
prospectively paid brachytherapy sources subject to the outlier 
provisions of section 1833(t)(5) of the Act. We note that we 
inadvertently did not show the necessary conforming regulation text in 
the proposed rule. Accordingly, we are making a conforming technical 
change to the regulation text at Sec.  419.43(f) to delete 
brachytherapy sources from the services and groups excluded from 
outlier payments.
    We noted in the proposed rule that HDR iridium-192 (code C1717) is 
a reusable source across treatment sessions and across patients. We 
believed that it was unclear whether hospitals had been reporting the 
number of units provided accurately, in accordance with our 
instructions to report one unit per treatment. Thus, while we proposed 
that HDR iridium be paid separately on the basis of the median cost per 
source as we proposed to pay for the other brachytherapy sources, we 
invited comments on alternatives to using this methodology for this 
source in particular, such as on the basis of median cost per treatment 
day from hospital claims.
    We received a large number of comments specifically addressing the 
CY 2007 OPPS proposal for payment of HDR iridium, including suggestions 
for alternatives to payment based on the median unit cost of the 
source.
    Comment: A number of commenters noted that the unit cost of HDR 
iridium is particularly variable, depending on the number of treatments 
provided by a hospital in a given calendar quarter before the source 
must be renewed. They believed that HDR iridium was, therefore, unlike 
most other OPPS services, for which hospital costs did not typically 
vary as greatly in relationship to service volume. They argued that 
providing payment at charges reduced to costs for this source, in 
particular, was important to ensuring patient access to HDR iridium 
treatment in their communities where the service volume may be low, 
such as at rural hospitals. Partial breast irradiation, with closely 
spaced treatments provided over a short time period in comparison with 
traditional treatment with external beam radiation therapy over many 
weeks, was cited as an important example of the value of HDR iridium in 
improving the care and quality of life for patients undergoing 
treatment for breast cancer.
    The commenters expressed concern that the proposed payment of 
$134.93 per fraction may provide inadequate payment, particularly to 
hospitals that do not provide a high volume of HDR brachytherapy, 
notably smaller and mid-sized hospitals. Some of the commenters agreed 
with our concern that hospitals may not be reporting accurate units and 
charges for this reusable source. The commenters recommended that HDR 
iridium should continue to be paid on a per treatment or per fraction 
basis, and not be paid per treatment day, due to the significant 
variations among different treatment protocols. Therefore, the 
commenters concluded that CMS should continue to pay for HDR iridium 
per fraction.
    A few commenters indicated that there is great variability in the 
cost of HDR iridium treatments, with such variations occurring because 
of the treatment site (for example, breast, uterus, prostate). These 
treatment variations result in differences in the resources needed, 
such as the number of source runs for each case. The commenters also 
indicated that our claims data for HDR iridium-192 presented huge 
variations in cost per unit source on claims and across hospitals, with 
costs ranging from $0 to $4,746. In addition, the commenters pointed 
out that the GAO report made no definitive recommendations regarding 
payment for the HDR iridium source. A number of commenters stated that 
CMS should continue to pay for HDR iridium based on the charges reduced 
to cost payment methodology.
    Response: Our proposal to pay for HDR iridium-192 on a per source 
basis, which is equivalent to a per treatment or per fraction payment 
for this brachytherapy source, factors in the clinical variability in 
the number of treatments per day with this source. HDR iridium is a 
radioactive source with a 90-day life span that is purchased and used 
multiple times in numerous patients over its life. During a treatment 
with HDR iridium, the radioactive source is briefly inserted into each 
temporary treatment catheter that has been placed into a patient's 
treatment area and then removed. It never comes in direct contact with 
the patient so it may be used for multiple patients. We believe that 
the cost of the radioactive source per treatment procedure is the same, 
irrespective of how many dwell positions or source runs are provided in 
the variable numbers of catheters placed in patients. However, we also 
understand that a per day payment methodology that does not take into 
consideration the number of treatments per day could be problematic, 
because the total day's source cost when more than one treatment is 
provided on a day for the same Medicare beneficiary would be 
significantly greater than if only one treatment was performed on that 
day. We believe that a per source payment, which equates to a per 
treatment payment, for HDR iridium as proposed is appropriate, given 
these considerations.
    Because HDR iridium has a fixed active life and must be replaced 
every 90 days, we agree with commenters that hospitals' costs for the 
source will be highly dependent on the number of treatments provided by 
a hospital during that time period. The source cost must be amortized 
over the life of the sources so, in establishing their charges for the 
HDR iridium source, we expect that hospitals would project the number 
of treatments that would be provided over the life of the source and 
establish their charges accordingly. In this respect, HDR iridium is 
similar to capital equipment that hospitals buy to perform procedures 
and that has a limited lifespan. Hospitals' costs for such equipment 
must be spread over their charges for the procedures performed, so the 
cost per procedure would vary significantly depending on the number of 
services provided.
    For most such OPPS services, our practice is to establish 
prospective payment rates based on the median hospital costs as 
calculated from claims data, to provide incentives for efficient and 
cost-effective delivery of these hospital services. We examined our 
full year CY 2005 claims data for HDR iridium, as suggested by the GAO, 
and found the hospital costs for this source did not vary much more 
than for the other brachytherapy sources, including

[[Page 68108]]

iodine and palladium. We note that, based on our analysis, on average 
the CY 2007 final rule median cost for HDR of $141.75 based on the 
source's median unit cost from CY 2005 claims would be about 7 percent 
higher than under the CY 2006 cost-based methodology, which yields an 
estimated median payment of $132.30, similar to the pattern observed 
for iodine and palladium sources. While we recognize that the average 
unit cost of an iridium source purchased by a hospital would be related 
to the number of treatments provided with the source and that hospitals 
must bill Medicare based on projections of their unit cost, we have no 
reason to believe that our CY 2007 final rule payment rate based on the 
median unit cost for HDR iridium would place continued access to this 
source at risk. Like many services under the OPPS for which hospitals 
purchase reusable equipment and supplies, hospitals' unit costs for 
iridium sources would vary based on the number of treatments a hospital 
provides before the source must be renewed, thus incurring additional 
costs. Again, under a PPS methodology, payments generally account for 
the average costs of services, and do not specifically account for 
varying circumstances. We believe that hospitals understand this 
prospective payment methodology and should recognize that a PPS could 
pay more or less than the cost of delivering a specific service in an 
individual case.
    Regarding the comment that the GAO report made no definitive 
recommendations regarding payment for the HDR iridium source, this 
recommendation was based on the lack of data produced by the GAO's own 
survey, and the report indicated that it was the GAO's opinion that CMS 
has outpatient claims data from all hospitals that have used iridium. 
The GAO recommended that, in order to identify a suitable methodology 
for separate payment for HDR iridium, CMS would be able to establish an 
average cost and evaluate whether that cost varies substantially and 
unpredictably. In the efficient delivery of high dose rate 
brachytherapy services, our claims data provide no evidence that the 
hospital costs associated with HDR iridium vary greatly and 
unpredictably, so we believe that our CY 2005 claims provide an 
appropriate basis upon which to establish the CY 2007 prospective 
payment rate for HDR iridium for each treatment. This rate should help 
ensure that hospitals continue to operate efficiently in providing HDR 
brachytherapy treatments to Medicare beneficiaries.
    Comment: One commenter recommended that CMS continue paying 
hospitals ``based on use of the HDR Iridium-192 source,'' but that CMS 
establish a maximum charge for HDR Iridium, that is, $700 per fraction. 
The commenter also suggested that each provider continue to establish a 
charge based upon the source costs per year divided by the number of 
fractions, thus allowing low volume HDR facilities to offer the 
service, while not overpaying high volume facilities.
    Response: We do not instruct hospitals on establishing charges or 
restrict hospital charges for items billed to Medicare. Hospitals 
establish charges based on many factors, including, but not limited to, 
the costs of items and services and the market conditions in the 
communities that they serve. Moreover, the OPPS is not a system that 
pays hospital charges. The OPPS rates generally are based upon relative 
weights calculated from Medicare claims data and converted to payment 
rates by a conversion factor. Prospective payment rates under the OPPS 
are based on the median cost for each APC from historical hospital 
claims, with trimming of claims data only at the extremes to eliminate 
those claims of exceptionally high or low cost from contributing to APC 
median cost development. The commenter did not indicate how a maximum 
charge would alleviate problems associated with making appropriate 
payments for HDR iridium to hospitals, or any goals such a policy would 
accomplish. Additionally, the commenter did not provide the basis of 
its recommendation that the maximum charge should be capped at $700 per 
fraction.
    Comments: A large number of commenters requested that iodine-125 
liquid brachytherapy solution, C2632 (which will be paid under A9527, 
effective January 1, 2007, as stated elsewhere in this section), which 
is used in patients with brain cancer, continue to be paid on the basis 
of charges reduced to cost. The commenters claimed that the proposed 
payment is insufficient to meet the cost of the iodine-125 (I-125) 
solution, along with handling and other administrative costs associated 
with the source. The commenters stated that hospitals must continue to 
be able to offer this vital brain cancer radiotherapy option. Several 
commenters believed that the proposed payment of $19.32 is not 
sufficient to cover the cost of one mCi, the 150-200 mCi in a 1 mL vial 
of I-125 solution, or the usual 150-450 mCi required for a typical 
case. One commenter noted that while appropriate coding requires 
reporting one unit per mCi, or 150 units per 1 mL vial, hospitals are 
confused regarding the correct unit of billing, which undermines the 
accuracy of data on which CMS relies. One commenter stated that the 
``actual hospital charge'' of a 1 mL vial of I-125 solution is $5,900, 
which at the rate of 150 mCi per vial is $39.33 per mCi, while our 
proposed payment rate was $19.32 per mCi.
    This commenter also mentioned that the APC Panel report from the 
March 2006 Panel meeting noted that some brachytherapy sources, 
including C2632, ``demonstrate relatively inconsistent mean and median 
numbers of sources used,'' and that CMS staff pointed out concerns 
about variability of the mean and median statistics. The commenter 
contracted an outside consultant to analyze CY 2005 OPPS claims data 
for C2632. The contractor concluded that there are wide variations in 
how hospitals billed for units of I-125 solution, which points to 
unreliable cost data on which to base payments for CY 2007.
    Response: The commenters did not establish why payment based on the 
median unit cost for the I-125 liquid brachytherapy solution is 
insufficient. Most commenters did not provide any information on the 
cost of a one mL vial of I-125 solution or sufficient further 
information supporting their claim that the proposed payment rate is 
insufficient. The commenter who stated that the ``actual hospital 
charge'' for a 1 mL vial of I-125 solution is $5,900 is a manufacturer 
of equipment that uses the I-125 solution for its brain cancer 
treatments and was the only commenter to provide some information on 
the cost of the I-125 solution. We note that we proposed to pay for the 
I-125 solution on a per mCi basis. This per source payment methodology 
is designed to capture the variability in costs per treatment, 
depending on the radiation dose. We also observe that the typical 
treatment of 150-450 mCi cited would receive payments between $2,898 
and $8,694 per treatment, at the proposed payment rate of $19.32 per 
mCi.
    We have issued instructions on the correct OPPS billing for the 
brachytherapy solution. Transmittal 132, Change Request 3154, dated 
March 30, 2004, notes how to account for the cost of handling and 
supervision related to radiation sources. The commenters claimed that 
hospitals are confused regarding the number of units of I-125 solution 
per vial. Our payment has historically been made on a per mCi basis, 
and this approach will continue for CY 2007, consistent with the 
predecessor C-code unit (C2632) and, for CY 2007, the permanent A-code 
unit (A9527). Therefore, when a vial of I-125

[[Page 68109]]

solution contains 150 mCi, there are 150 billing units of I-125 
solution per vial, resulting in an OPPS payment, if all billing units 
are used, of $2,898 based on the CY 2007 proposed payment rate.
    CMS staff did point out to the APC Panel at the March 2006 meeting 
our concerns about variability in statistics for numbers of sources 
used and wondered whether significant differences between the median 
and mean mCi reported per day could point to coding confusion regarding 
the correct billing of units for individual cases. We asked the Panel 
members to respond and provide any recommendations. Individual Panel 
members familiar with brachytherapy source costs, as well as the Data 
Subcommittee in general, believed that the median costs per unit 
appeared to generally be reasonable for the most commonly furnished 
sources, but that erroneous billing of the units of sources could 
affect the median unit costs of some sources, including C2632. We are 
continuing to study the variability of brachytherapy source data, and 
note that there are significantly greater units for some sources, such 
as C2632, based on full year CY 2005 data, than were included in the 
partial CY 2005 data the Panel reviewed in March 2006. We believe it is 
appropriate to treat I-125 solution like all other brachytherapy 
sources for CY 2007 and establish its payment rate based on its median 
unit cost from CY 2005 claims data.
    Comment: One commenter did not believe we had factored into the 
cost of brachytherapy the need for special handling of sources by 
nuclear physicists and sought payment consideration for these handling 
costs.
    Response: We explicitly consider the special handling of 
brachytherapy sources by nuclear physicists in our ratesetting 
policies. We instructed providers, in Transmittal 132, Change Request 
3154, dated March 30, 2004, to report charges for the supervision, 
handling, and loading of radiation sources, including brachytherapy 
sources, in one of two ways: report the charge separately using CPT 
77790, in addition to reporting the associated HCPCS procedure code(s) 
for application of the radiation source; or include the charge as part 
of the charge reported with the HCPCS procedure code(s) for application 
of the radiation source. (We further noted in that transmittal that 
providers should not bill a separate charge for brachytherapy source 
storage costs, which are treated as part of the department's overhead 
costs.) Reporting in either of these ways results in the costs of 
special handling being packaged into payments for brachytherapy 
procedures.
    Comment: Some commenters asked that CMS continue to pay for 
brachytherapy sources on the basis of charges reduced to cost because 
the APC Panel and Practicing Physicians Advisory Council (PPAC) 
recommended it. They also stated that continuation of payment based on 
charges reduced to cost would ensure that there are no barriers to 
access and would avoid their concerns with CMS data. The commenters 
stated that payment based on this methodology has worked well for the 
past 2 years and should be continued for at least CY 2007 and CY 2008. 
Noting the GAO report was due no later than January 1, 2005, the 
commenters believed that the intent of Congress in section 621(b) of 
the MMA was to provide 2 years of payments for brachytherapy sources 
based on charges reduced to cost after the publication of the GAO study 
to allow no less than 2 years for Congress, CMS, and the public to 
further analyze brachytherapy device cost and payment information, and 
the findings of the GAO survey in particular, before payment based on 
charges reduced to cost would cease. They believed that CMS should 
continue payment based on charges reduced to cost for CY 2007 and CY 
2008 to comply with what they viewed as the intent of Congress, because 
the GAO report was not released until July 2006, about 18 months after 
its due date of January 1, 2005, for publication.
    One commenter supported the concept of prospective payment for 
brachytherapy sources when the payment rates can be based on data that 
are stable over time and reasonably accurate. The commenter believed 
that the GAO report was sound, and it supported the GAO's 
recommendations regarding payment of C1718, iodine-125, per source and 
C1720, palladium-103, per source. For other sources, the commenter 
recommended that CMS continue to pay on the basis of charges reduced to 
cost. The commenter believed this was especially important for HDR 
iridium, which entails particular data challenges in developing an 
accurate per treatment or per fraction median cost.
    Response: We recognize that at its August 2006 APC Panel meeting, 
the Panel recommended that CMS continue the current methodology of 
charges reduced to cost using the overall hospital CCR for payment of 
brachytherapy sources for 1 year (see recommendations of the APC Panel 
at http://www.cms.hhs.gov/FACA/). The Panel reviewed a letter of 
comment on this issue requesting continuation of the CY 2006 cost-based 
payment methodology for CY 2007, but no public presentation was heard. 
While we acknowledge the Panel's recommendation, we note that the Panel 
did not provide specific rationale for its recommendation, nor did it 
provide an explanation of what it perceived to be the problem with the 
proposed median costs. Accordingly, we do not choose to adopt the 
Panel's recommendation.
    We also acknowledge that the PPAC recommended that CMS abandon the 
proposal to pay for brachytherapy sources based on median unit costs 
calculated from claims data and reexamine its claims data for sources 
(see recommendation 57 H.1 in the summary of the August 2006 PPAC 
meeting at http://www.cms.hhs.gov/FACA/). The Panel's discussion of the 
issue at its August 2006 meeting centered on its belief that hospitals 
incorrectly reported HCPCS codes and charges for brachytherapy sources. 
However, as discussed in detail previously, we observe significant 
stability of claims-based costs for the most commonly used sources over 
time, and hospitals have generally had 6 years of experience with 
reporting the codes and charges for brachytherapy sources, upon which 
their specific source payments were based throughout that time period. 
Therefore, as we do not agree with the underlying rationale behind 
PPAC's recommendation, we are likewise not accepting its 
recommendation.
    We also note that the statute requires payment based on charges 
reduced to cost for sources furnished between January 1, 2004, and 
December 31, 2006. The law is clear as to the timeframe for this 
payment approach and is not linked to the issuance of the GAO report, 
as commenters suggested was the intent of Congress. Moreover, we have 
considered the GAO's findings in setting prospective payment rates for 
sources of brachytherapy, which we believe is fully consistent with the 
provisions of the MMA.
    Comment: A few commenters recommended that CMS institute mandatory 
device code edits for brachytherapy procedures assigned to APCs 0312, 
0313, and 0651, requiring the reporting of alphanumeric HCPCS codes for 
brachytherapy sources, which are always required for the delivery of 
brachytherapy. More generally, the commenters stated that they support 
expanding the CY 2007 device edit policy to all device-related APCs. 
They also remarked that the CMS source data were insufficiently 
representative of actual source costs because many hospitals that 
charged for brachytherapy

[[Page 68110]]

procedures did not include codes and charges for sources on the claims 
for these procedures, which could not have been performed without the 
use of brachytherapy sources. The commenters asked that CMS require 
hospitals to bill the alphanumeric HCPCS codes for sources as a 
condition of being paid for the brachytherapy procedures that cannot be 
performed without sources, in order to promote correct coding and to 
improve the quality of the claims data. The commenter also believed 
that hospitals should be educated regarding how to report charges for 
brachytherapy sources used in the outpatient department.
    Response: Device edits are appropriate for APCs that have the costs 
of the relevant devices packaged into the costs of the procedural APCs. 
We require device edits for certain APCs in order to ensure that 
charges for the required devices are included on the claims, so that 
payments for device costs are appropriately packaged into the payments 
for the procedures that use the devices. Moreover, we impose device 
edits in association with specific procedures only when an item is of 
significant cost whose payment is packaged into the APC payment for the 
procedure. We do not impose claims edits for items, such as 
brachytherapy sources, that are separately paid and for which hospitals 
have a very strong incentive to bill Medicare. Specifically, APCs 0312, 
0313, and 0651 do not have payment for the costs of brachytherapy 
sources packaged into the procedural APC payments. We believe that 
hospitals that furnish brachytherapy services either bill us for the 
sources separately using their alphanumeric HCPCS codes or apparently 
choose to package the charges for the sources into charges for the 
services in which they are applied and not seek separate payment for 
the sources. The latter reporting practice would lead to our 
overestimation of the costs of brachytherapy procedures. In addition, 
if hospitals include the charges for the sources in the charges for the 
procedures in which they are applied, a requirement for reporting of 
codes for the sources could result in these hospitals billing token 
charges, thus undermining the correct determination of the unit cost 
per source.
    As required by the law, we currently are paying separately for 
brachytherapy sources, as we have been for most sources every year 
since the beginning of the OPPS in CY 2000. We will be paying for 
sources separately in CY 2007 as well. Because payments are provided 
separately for brachytherapy sources reported with specific HCPCS 
codes, device edits are not needed to ensure appropriate payments for 
brachytherapy procedures. The reporting of brachytherapy source HCPCS 
codes is required for hospitals to receive payment for brachytherapy 
sources, and this should be sufficient incentive for providers to 
report brachytherapy source codes.
    After consideration of the comments received, as well as the 
recommendations of the APC Panel, the PPAC, and the GAO, we have 
decided to base payment for all sources of brachytherapy for which we 
have CY 2005 claims on their median unit costs derived from CY 2005 
OPPS claims data. We refer readers to Addendum B of this final rule 
with comment period for the CY 2007 national payment rates and 
copayments for the sources of brachytherapy. We note that there is a 
new permanent Level II alphanumeric HCPCS codes for iodine-125 
brachytherapy solution for CY 2007. The new code, A9527, has a long 
descriptor, Iodine I-125, sodium iodide solution, therapeutic, per 
millicurie, that describes the same brachytherapy source as the 
predecessor C-code, C2632, Brachytherapy solution, iodine 125, per mci, 
for which we are currently making separate payment under the OPPS. As 
of January 1, 2007, with the effective date of HCPCS code A9527, we 
will delete C2632. We will crosswalk claims data and establish the 
prospective payment rate for A9527 based on our CY 2005 claims for 
C2632. Table 30 in this final rule with comment period contains the 
median costs of brachytherapy sources from CY 2005 claims data and the 
HCPCS codes to be used in CY 2007 to report these devices.
    Therefore, we are finalizing our proposed payment methodology for 
brachytherapy sources based upon their median unit costs from CY 2005 
claims data for CY 2007 without modification. While this methodology is 
fully consistent with the statutory requirement of separate payment for 
brachytherapy sources based on their number, isotope, and radioactive 
intensity, it will also provide hospitals with an incentive to operate 
efficiently in providing brachytherapy services to Medicare 
beneficiaries.
    Because brachytherapy sources will no longer be paid on the basis 
of their charges reduced to cost, we proposed to discontinue our use of 
payment status indicator ``H'' for APCs assigned to brachytherapy 
sources. We proposed to use status indicator ``K'' for all 
brachytherapy source APCs for CY 2007. We also proposed for CY 2007 to 
change the definition of status indicator ``K'' to ensure that ``K'' 
appropriately describes brachytherapy source APCs. Payment status 
indicators are discussed in section XV.A. of the preamble of this final 
rule with comment period.
    We did not receive any public comments specific to the proposal to 
change the status indicator definitions for brachytherapy sources. 
Therefore, we are adopting as final for CY 2007, without modification 
our proposed changes to the definitions of status indicators ``H'' and 
``K'' to address CY 2007 brachytherapy source payment.
    Table 30 below provides a complete listing of the HCPCS codes, long 
descriptors, APC assignments, median costs, and status indicators that 
we will use for brachytherapy sources paid separately under the OPPS in 
CY 2007.

                         Table 30.--Separately Payable Brachytherapy Sources for CY 2007
----------------------------------------------------------------------------------------------------------------
                                                                                                       CY 2007
             HCPCS code                       Long descriptor          CY 2007 APC  CY 2005 median     status
                                                                                         cost         indicator
----------------------------------------------------------------------------------------------------------------
C1716...............................  Brachytherapy source, Gold 198,         1716          $36.61            K
                                       per source.
C1717...............................  Brachytherapy source, High Dose         1717          141.75            K
                                       Rate Iridium 192, per source.
C1718...............................  Brachytherapy source, Iodine            1718           36.12            K
                                       125, per source.
C1719...............................  Brachytherapy source, Non-High          1719           23.01            K
                                       Dose Rate Iridium 192, per
                                       source.
C1720...............................  Brachytherapy source, Palladium         1720           48.53            K
                                       103, per source.
C2616...............................  Brachytherapy source, Yttrium-          2616       10,525.13            K
                                       90, per source.
A9527 (C2632 deleted)...............  Iodine I-125, sodium iodide             2632           20.30            K
                                       solution, therapeutic, per
                                       millicurie.
C2633...............................  Brachytherapy source, Cesium-           2633           90.31            K
                                       131, per source.

[[Page 68111]]

 
C2634...............................  Brachytherapy source, High              2634           32.49            K
                                       Activity, Iodine-125, greater
                                       than 1.01 mCi (NIST), per
                                       source.
C2635...............................  Brachytherapy source, High              2635           54.25            K
                                       Activity, Palladium-103,
                                       greater than 2.2 mCi (NIST),
                                       per source.
C2636...............................  Brachytherapy linear source,            2636           39.28            K
                                       Palladium-103, per 1MM.
----------------------------------------------------------------------------------------------------------------

    As indicated in our CY 2007 OPPS proposed rule (71 FR 49598), there 
was one source for which we had no claims data or payment information 
from the CY 2005 claims data available for the development of the 
proposed rule, and this statement remains true based on our recent 
analysis of complete CY 2005 claims data for this final rule with 
comment period. We added Ytterbium-169 (HCPCS code C2637) for payment 
effective October 1, 2005, because it met the requirements of section 
1833(t)(2)(H) of the Act as a separate brachytherapy source. It was our 
understanding at the time of development of the proposed rule that this 
source, which is for use in HDR brachytherapy, was not yet marketed by 
the manufacturer, although it had been approved by the Food and Drug 
Administration (FDA). Therefore, we had no claims data for this 
brachytherapy source in order to develop a prospective payment rate, as 
we did for the other brachytherapy sources for CY 2007. In addition, it 
was our understanding that no price for the product existed, as it had 
not yet been marketed. Thus, we also had no external information 
regarding the cost of this source to hospitals. We weighed our payment 
options for CY 2007 for brachytherapy sources for which we had no 
payment or claims information, such as the present case with Ytterbium-
169. This included considering our CY 2007 payment options for other 
new brachytherapy sources that come to our attention, which 
historically have been newly recognized under the OPPS on a quarterly 
basis. We discussed these payment options in our CY 2007 OPPS proposed 
rule (71 FR 49598 and 49599), and they are reviewed below.
    One option for CY 2007 was to pay for the currently existing HCPCS 
code C2637 for Ytterbium-169 at charges converted to cost. However, 
this would be inconsistent with our final policy with regard to payment 
for brachytherapy sources under prospectively established payment 
rates. The law specifically required us to pay for all brachytherapy 
sources based upon charges converted to cost for CYs 2004 through 2006. 
However, that provision will expire for the CY 2007 OPPS. In addition, 
this methodology would be inconsistent with the prospective payment 
methodologies we use to provide payments for other new items and 
services under the OPPS for which we do not yet have claims data.
    A second option was to assign the code to its own APC or to a New 
Technology APC with a payment rate set at or near the lowest CY 2007 
payment rate for any source of brachytherapy paid on a per source basis 
(as opposed, for example, to per mci), for CY 2007. However, we had no 
claims data or other information regarding the cost of HCPCS code C2637 
to hospitals. This payment policy would resemble our policy regarding 
the APC assignment of not otherwise classified codes, which are 
assigned to the lowest level APC in their clinically compatible series. 
However, HCPCS code C2637 is a specifically defined brachytherapy 
source, and such a payment rate would not recognize the clinical 
distinctions among brachytherapy sources, including their differences 
in isotopes and radioactive intensities, that are relevant to their 
clinical uses in low dose rate (LDR) versus HDR brachytherapy. The 
solid brachytherapy source with the lowest final median cost for CY 
2007 is HCPCS code C1719, for non-HDR Iridium-192, with a median cost 
of $23.01 per source, which is implanted in LDR brachytherapy.
    A third option was to assign HCPS code C2637 to its own APC or to a 
New Technology APC with a payment rate established at or near the 
proposed payment rate for HCPCS code C1717, which describes HDR 
Iridium-192. Like HCPCS code C2637, HCPCS code C1717 is used for HDR 
brachytherapy, and HCPCS code C1717 is the most commonly used source 
for HDR brachytherapy under the OPPS. However, this approach would not 
take into consideration significant differences in the two sources, 
including their radioactive isotopes and energy levels.
    The fourth option was to assign HCPCS code C2637 to its own APC or 
to a New Technology APC with a prospective payment rate based on 
external data provided to us regarding the expected cost of the source 
to hospitals. If we were provided reliable and relevant cost 
information for the source, we could establish its payment rate based 
on that information and our review of other pertinent considerations, 
as we do for new technology services under the OPPS. Under this option, 
in the absence of external cost information, we would not recognize 
HCPCS code C2637 under the OPPS for CY 2007 until we received such 
information and could establish a payment rate in a quarterly OPPS 
update. We provided the brachytherapy source Ytterbium-169 a HCPCS code 
in CY 2005 at the manufacturer's request, based on the belief that the 
source would be marketed shortly. However, the product has not yet been 
marketed. Therefore, we recognize a HCPCS code for an item that is not 
currently available to hospitals. We do not typically issue and 
maintain as payable a HCPCS code for an item that is not marketed. 
Under this option, if the source were marketed mid-quarter in CY 2007 
and cost information was provided to us, there would be no payment 
available for the source until the next OPPS quarterly update, which 
would establish the payment rate for HCPCS code C2637 and its effective 
date.
    After weighing the above options, we proposed the second option 
discussed, that is, to assign C2637 to its own APC or a New Technology 
APC with a payment rate set at or near the lowest proposed payment rate 
for any source of brachytherapy paid on a per source basis. This option 
resembled our policy regarding the APC assignment of not otherwise 
classified codes, in the absence of any data currently available. Once 
we had claims data, or obtain external data, we could consider movement 
to another APC, if warranted.
    We specifically invited comments on how we should establish the CY 
2007 payment amount for Ytterbium-169 (HCPCS code C2637), especially 
with consideration of the four options discussed above, and on how we 
should generally proceed in the future to set

[[Page 68112]]

payment amounts for established or new brachytherapy sources eligible 
for separate payment under section 1833(t)(2)(H) of the Act, for which 
we have no claims-based cost data.
    We received a number of public comments concerning our four 
proposed CY 2007 payment options for Ytterbium-169 and/or other new 
brachytherapy sources without hospital costs from claims data. A 
summary of the comments and our responses follow.
    Comment: A few commenters recommended that we pay for ytterbium, 
and other new or established brachytherapy sources when no hospital 
claims data are available, at charges reduced to cost, which was 
generally the commenters' recommendation on payment for all sources. 
Several commenters claimed that ytterbium would be available to 
hospitals in CY 2007. The commenters noted that ytterbium is an HDR 
source with unique characteristics and that, as described in its 
original request to CMS for a HCPCS code, ytterbium has a shorter half-
life than HDR Iridium-192, requiring replacement every 32 days versus 
90 days for HDR iridium. The commenters also noted different shielding 
and target activity for ytterbium in comparison with HDR iridium. 
Because there are no other sources comparable to ytterbium, some 
commenters believed the most appropriate payment methodology was 
charges reduced to cost for a minimum of 2 years, while CMS collects 
claims data. The commenters believed that CMS should similarly employ 
the payment methodology of charges reduced to cost for other new 
sources when there are no hospital claims data available. A number of 
commenters recommended that CMS pay for new sources on the basis of 
charges reduced to cost for a period of 3 years.
    Reponse: The commenters presented no compelling arguments that new 
sources for which there are no claims data need to be paid at charges 
reduced to cost. Such an approach is contrary to the way we generally 
pay for other new nonpass-through items and services based on 
prospective payment rates through their APCs in the OPPS. We note that 
none of the commenters, including the manufacturer of ytterbium, 
provided the cost of that source when it reportedly will be marketed in 
CY 2007. However, we agree with the commenters that we need to pay 
appropriately for new brachytherapy sources in order to ensure 
continued developments in the technology. We have determined that our 
proposed option, to pay for new brachytherapy sources based upon the 
lowest per source payment rate of currently available sources, could 
provide payments for new sources that were too low to permit continued 
new developments in brachytherapy technology. Therefore, after weighing 
the comments and the four options, we are adopting as final the fourth 
option discussed for CY 2007. That is, we would assign future new HCPCS 
codes for new brachytherapy sources to their own APCs, with prospective 
payment rates set based on our consideration of external data and other 
relevant information regarding the expected costs of the sources to 
hospitals. This approach is consistent with our usual treatment of new 
technologies under the OPPS. We do not pay for new technologies, other 
than pass-through devices, under the OPPS at charges adjusted to cost. 
Instead, for new technology services we utilize external data and other 
information available to us, including claims data on related services, 
to establish appropriate New Technology APC assignments for new 
services until we have costs from claims data specific to the new 
services. We would not assign a brachytherapy source to a New 
Technology APC because such APCs contain only services, and, according 
to the statute, we are to establish separate groups for payment of 
brachytherapy sources reflecting their number, isotope, and radioactive 
intensity. Therefore, when we establish HCPCS codes for new 
brachytherapy sources, we will utilize external data and other 
information available to us to establish a prospective payment rate 
specific to the source, for use until we have hospital costs from 
claims data. Consistent with this practice, although we solicited 
specific comments on payment for the ytterbium source in the CY 2007 
proposed rule, to date we have received no cost data and have no other 
information that we could use to establish an informed prospective 
payment rate for the source. Therefore, we are assigning C2637 the 
nonpayable status indicator ``B'' for January 1, 2007, because we have 
no claims information or external cost data that would allow us to 
assign C2637 to its own APC with a prospective payment rate. Should we 
later receive relevant information, we could establish a payable status 
indicator and appropriate payment rate for the ytterbium source in a 
future OPPS quarterly update.
    In our CY 2007 OPPS proposed rule, we again invited the public to 
submit recommendations for new HCPCS codes to describe new 
brachytherapy sources in a manner reflecting the number, isotope, and 
radioactive intensity of the sources (71 FR 49599). We requested that 
commenters provide a detailed rationale to support recommended new 
sources and send recommendations to us. We noted that we would continue 
our endeavor to add new brachytherapy source codes and descriptors to 
our systems for payment on a quarterly basis (71 FR 49599). We 
specified that such recommendations should be directed to the Division 
of Outpatient Care, Mail Stop C4-05-17, Centers for Medicare & Medicaid 
Services, 7500 Security Boulevard, Baltimore, MD 21244.
    As indicated in the CY 2007 OPPS proposed rule (71 FR 49599), we 
had considered the definition of the term ``brachytherapy source'' in 
the context of current medical practice, and in light of the language 
in section 1833(t)(2)(H) of the Act. We proposed to define a device of 
brachytherapy eligible for separate payment under the OPPS as a ``seed 
or seeds (or radioactive source)'' as indicated in section 
1833(t)(2)(H) of the Act, which refers to sources that are themselves 
radioactive, meaning that the sources contain a radioactive isotope. 
Therefore, for example, we proposed that we would not consider specific 
devices that did not utilize radioactive isotopes to deliver radiation 
to be radioactive sources as envisioned by the statute.
    We received numerous public comments in response to our request for 
new brachytherapy source recommendations and our proposed definition of 
the term ``brachytherapy sources.'' A summary of the comments and our 
responses follow.
    Comment: A large number of commenters disagreed with our proposed 
definition of brachytherapy sources for separate payment for a variety 
of reasons. Several commenters stated that our definition based on 
section 1833(t)(2)(H) of the Act was too narrow, and should be 
broadened to include new and innovative nonradioactive sources, such as 
``electronic'' brachytherapy sources. The commenters indicated that 
brachytherapy sources do not need to be radioactive to deliver 
therapeutic doses of brachytherapy. They recommended that CMS consider 
all new technologies now FDA-cleared for brachytherapy and broaden our 
definition for separate payment to include innovative radioactive and 
nonradioactive sources. Many commenters believed that adopting the 
proposed definition of brachytherapy sources for separate payment would 
prevent Medicare beneficiary access to care and hamper the development 
of new cancer therapies, such as ``electronic'' brachytherapy. Some 
commenters indicated that brachytherapy is not

[[Page 68113]]

defined by the type of source used to treat the cancer, but by the 
treatment that is delivered to the patient. A few commenters stated 
that, through discussions with legislators, it was their understanding 
that the intent of the legislation was to provide separate payment for 
all devices of brachytherapy and not to exclude any devices.
    Reponse: As indicated in the CY 2007 OPPS proposed rule (71 FR 
49599) and reiterated in this preamble above, we considered the 
definition of ``brachytherapy source'' in the context of current 
medical practice and in regard to the language in section 1833(t)(2)(H) 
of the Act, which refers to brachytherapy sources as ``a seed or seeds 
(or radioactive source).'' We continue to believe that this provision 
of the Act mandating separate payment refers to sources that are 
themselves radioactive, meaning that the source contains a radioactive 
isotope. Furthermore, the statutory language is likewise clear that 
devices of brachytherapy paid for separately must reflect ``the number, 
isotope, and radioactive intensity of such devices furnished'.'' 
Accordingly, we further believe that section 1833(t)(2)(H) of the Act 
applies only to radioactive devices of brachytherapy.
    We point out that forms of radiation delivery such as 
nonradioactive brachytherapy, which was used by commenters as the 
principal example of other forms of brachytherapy, do not constitute a 
brachytherapy source as contemplated by the statute. In addition to not 
containing a radioactive isotope, these forms of radiation delivery are 
dependent on external equipment to deliver therapeutic radiation to the 
treatment sites within the body.
    Therefore, we will not consider specific devices, beams of 
radiation, or equipment that do not constitute separate sources that 
utilize radioactive isotopes to deliver radiation to be brachytherapy 
sources for separate payment, as such items do not meet the statutory 
requirements provided in section 1833(t)(2)(H) of the Act.
    Comment: A few commenters claimed that section 1833(t)(2)(H) of the 
statute does not limit CMS to consider as new brachytherapy sources 
seeds or radioactive sources that are themselves radioactive. Some 
commenters cited section 1833(t)(2)(H) of the Act, while others defined 
current cancer therapies as ``a drug or biological that is used in 
cancer therapy, including (but not limited to) a chemotherapeutic 
agent, an antiemetic, a hematopoietic growth factor, a colony 
stimulating factor, a biological response modifier, a bisphosphonate, 
and a device of brachytherapy * * *'' and cited section 1833(t)(6) of 
the Act as authority for that definition. The commenters then stated 
that this definition did not require that a device of brachytherapy 
consist of a seed or seeds or radioactive sources, as we proposed, and 
that section 1833(t)(6) of the Act allegedly clearly indicated ``but 
not limited to,'' such that this list was not exclusionary. Another 
advocate of creating a new source code for ``electronic'' 
brachytherapy, cited section 1833(t)(2)(B) of the Act, which generally 
indicated that the Secretary may establish groups of services within 
the classification system that are comparable clinically and with 
respect to resources. Therefore, the commenters believed CMS should be 
able to group ``electronic'' brachytherapy with other sources, if they 
are comparable.
    Reponse: The commenters miscite the statute, erroneously implying 
it is part of section 1833(t)(2)(H) of the Act. Section 
1833(t)(6)(A)(ii) of the Act is the source of the commenters' quote and 
does not deal with separate payment of brachytherapy sources. Rather, 
the context of the quote is pass-through treatment of cancer therapies 
current when the Balanced Budget Refinement Act (Pub. L. 106-113) was 
enacted. The statutory authority mandating separate groups for payment 
discussed above is based on section 1833(t)(2)(H) of the Act. 
Specifically, section 1833(t)(2)(H) of the Act clearly states: ``With 
respect to devices of brachytherapy consisting of a seed or seeds (or 
radioactive source), the Secretary shall create additional groups of 
covered OPD services that classify such [brachytherapy] devices 
separately from the other services * * * in a manner reflecting the 
number, isotope, and radioactive intensity of such devices furnished * 
* *.'' We believe that Congress clearly limited any requirement for 
separate payment of brachytherapy sources to those which reflect the 
number, isotope, and radioactive intensity of the sources and to a 
``seed or seeds (or radioactive source)'' as stated in section 
1833(t)(2)(H) of the Act. Furthermore, while section 1833(t)(2)(B) of 
the Act provides the authority to create new APCs to group similar 
services together or distinguish new and/or different services to group 
together in terms of clinical characteristics and resource costs, it 
must be read in conjunction with the requirements given in section 
1833(t)(2)(H) of the Act. We do not believe that nonradioactive devices 
that deliver radiation are appropriately grouped with brachytherapy 
sources for separate payment, given that the statute also requires 
separate payment groups for brachytherapy sources to reflect the 
number, isotope, and radioactive intensity of the sources. We also 
remind the commenters that payment for devices under the OPPS, other 
than brachytherapy devices and those devices described by categories 
with active pass-through status, is packaged into the procedural APC 
payments for those services in which they are used.
    Comment: A few commenters supported our definition of brachytherapy 
source.
    Reponse: We appreciate the support for our proposal.
    Comment: Another commenter requested a clarification regarding the 
definition of ``source,'' claiming that the word source leaves unclear 
whether multiple brachytherapy seeds would constitute multiple sources, 
or, because they are all implanted at one time, they would constitute a 
single source.
    Reponse: Multiple brachytherapy seeds implanted during a single 
treatment session constitute multiple sources for billing on the claim 
to Medicare. For example, if 50 brachytherapy seeds are implanted, a 
hospital should report on its claim to CMS that it used 50 units of the 
source.
    Comment: Several commenters recommended that CMS establish new 
HCPCS codes and descriptors for separate payment of additional 
brachytherapy sources. Specifically, several commenters recommended 
that CMS establish new codes for stranded sources, namely Iodine-125, 
Palladium-103, RAPID Strand Iodine-125 (a brand of iodine-125), and 
cesium-131 sources in CY 2007. Possible new codes and descriptors 
suggested for two of the stranded sources were: C26xx, Brachytherapy 
device, Stranded Iodine-125, per source; and C26xx, Brachytherapy 
device, Stranded Palladium-103, per source. One commenter recommended 
that CMS create a new source code for separate payment based on its 
product name: C26xx, Brachytherapy device, RAPID Strand Iodine-125, per 
source.
    A few commenters recommended that CMS establish a new source code 
for separate payment as follows: Brachytherapy device, Stranded Cesium-
131, per source. The commenters described stranded brachytherapy 
sources as embedded into the stranded suture material and separated 
within the strand by material of an absorbable nature at specified 
intervals. They claimed that this approach ensured the initial and 
long-term position of each source when implanted in and around tumors. 
The

[[Page 68114]]

commenters claimed that stranded sources were different from 
``traditional'' sources in a number of ways, such as improved patient 
safety and clinical outcomes in the treatment of prostate cancer; 
increased production costs; requirements for separate FDA clearances; 
and potential for permitting greater radioactive intensity for 
treatment of specific patients because of their more precise 
positioning. The commenters further claimed that stranded sources could 
be placed at the periphery of the prostate or outside the prostate 
gland, permitting treatment of extra-prostatic extension of cancer 
without the potential for migration into another body organ. The 
commenters also pointed out that CMS has separately coded differences 
in configurations of previously established isotopes among 
brachytherapy source codes (that is, linear palladium-103 is separately 
coded as C2636). Some commenters claimed that thousands of Medicare 
patients received stranded iodine and palladium in CY 2006, whose 
specific costs would not have been reflected through separate codes for 
these source variants.
    Some commenters asserted that the lack of separate coding results 
in no separate data on the clinical practice for stranded sources. They 
claimed that CMS' CY 2005 data do not reflect important new clinical 
protocols that have emerged over the past few years, which have 
resulted in increased clinical use of stranded and ``custom-stranded'' 
sources for the treatment of prostate cancer. The commenters indicated 
that absence of data concerning stranded brachytherapy sources was a 
significant flaw in CMS' current data because stranded sources were 
distinct from traditional brachytherapy sources.
    Reponse: Section 1833(t)(2)(H) of the Act requires the creation of 
separate APC groups for brachytherapy sources that reflect the number, 
isotope, and radioactive intensity of the brachytherapy devices 
(sources) furnished. Stranding of existing sources of a certain 
isotope, such as iodine or palladium, is a specific clinical 
configuration that does not affect the number, isotope, and radioactive 
intensity of the brachytherapy sources, and thus would not lead to a 
separate APC grouping. While we created a new source code, C2636, 
linear palladium-103, per 1 mm, even though a code already existed for 
palladium-103 (C1720), we determined that the linear palladium source 
led to a change in the number of sources used, because it required a 
different, and therefore separate, measurement, per millimeter, as 
opposed to per source (that is, seed).
    We agree that it is probable that thousands of Medicare patients 
received stranded iodine and palladium in CY 2006, and further agree 
that stranded iodine and palladium are likely well-represented in our 
historical claims data, such that stranded source costs and utilization 
are reflected in the source codes for iodine and palladium, C1718 and 
C1720, respectively. Therefore, their use should be well-represented in 
the respective median costs for these C-codes in our CY 2005 data used 
to establish CY 2007 payment rates. The GAO drew similar conclusions in 
its study of brachytherapy source purchase prices, where they believed 
that their purchase price data reflected information across the full 
spectrum of brachytherapy source configurations provided by hospitals 
during the study period. Neither the GAO data nor the CY 2005 Medicare 
claims data reflect significant variation in the hospital costs of 
iodine and palladium sources. Our preferred treatment of iodine, 
palladium, and cesium sources is consistent with our general 
expectation that, as technology evolves and grows in utilization, the 
costs of the newer technologies will increasingly be reflected in the 
claims data used to establish prospective payment rates for future 
services.
    Accordingly, we are not creating new brachytherapy source codes for 
separate payment for stranded iodine-125, stranded palladium-103, RAPID 
Strand Iodine-125, or stranded cesium-131 sources.
    Comment: A number of commenters recommended that CMS establish a 
new brachytherapy source code and descriptor for ``electronic'' 
brachytherapy, effective January 1, 2007, with the following 
recommended code descriptor: C26xx, Brachytherapy device, High Dose 
Rate X-ray radiation, per source. The commenters made no recommendation 
on how to define ``per source.'' The commenters stated that 
technological advances demonstrate that nonradioactive sources can 
deliver a therapeutic radiation dose similar to a radioactive source or 
seed. They claimed that brachytherapy treatment does not define the 
type of source; instead, it defines a type of treatment and there may 
be many kinds of sources used in such treatments.
    Response: We agree that nonradioactive sources may be capable of 
delivering a therapeutic radiation dose similar to a radioactive source 
or seed. However, we believe that nonradioactive sources do not meet 
the definition of brachytherapy sources for separate payment under 
section 1833(t)(2)(H) of the Act as previously indicated in our 
discussion of the definition of brachytherapy sources eligible for 
separate payment. Consistent with our discussion of the definition of a 
brachytherapy source, we are not creating a new brachytherapy source 
code for separate payment for ``electronic'' brachytherapy.
    Comment: One commenter, the manufacturer of the Intrabeam system, 
recommended that CMS designate the radiation source used in the 
Intrabeam procedure as a brachytherapy device and provide separate 
payment for the source. The commenter claimed the radiation from the 
Intrabeam system is delivered directly into a tumor cavity, and 
therefore, by definition, is a form of brachytherapy. The commenter 
also claimed that the Intrabeam radiation source is a point source that 
is similar to other brachytherapy sources, such as seeds or pellets. 
The commenter stated that the wording of section 1833(t)(2)(H) of the 
Act, ``with respect to devices of brachytherapy consisting of a seed or 
seeds (or radioactive source), the Secretary shall create additional 
groups of services * * *'' to establish separate brachytherapy source 
payment would include the Intrabeam brachytherapy source within that 
definition of a source. The commenter argued that the temporarily 
activated gold of the Intrabeam system is a radioactive source as 
described in the statute. The commenter claimed that the statutory 
language does not limit brachytherapy sources to only radioactive 
isotopes, as is evidenced by the more general language ``or radioactive 
source.''
    Response: Based on the commenter's description, the Intrabeam 
system relies upon a miniature x-ray source, where electron beams 
travel to strike a gold target and x-rays are then emitted to treat the 
tissue surrounding a tumor cavity. The Intrabeam procedure uses 
external equipment to generate the electron beam, and the gold target 
is not itself a radioactive isotope used to provide radiation 
treatment. As noted previously, such forms of brachytherapy do not 
constitute a brachytherapy source as contemplated by the statute. In 
addition to not containing a radioactive isotope, such forms of 
radiation delivery are dependent on external equipment to deliver 
therapeutic radiation to the treatment sites within the body. The 
statute requires us to establish separate payment groups for 
brachytherapy sources that classify them separately based on their 
number, isotope, and radioactive intensity. We do not believe the 
concept of an isotope applies to the

[[Page 68115]]

Intrabeam system. Therefore, we are not creating a new brachytherapy 
source code for separate payment for the radiation source used in the 
Intrabeam system.
    After carefully considering the public comments received, we are 
not accepting any of the recommendations provided above by commenters 
for the establishment of new HCPCS codes to describe new brachytherapy 
sources for CY 2007. However, consistent with our general practice, we 
will consider recommendations submitted by the public for new 
brachytherapy sources during CY 2007, as discussed earlier. In 
addition, we are adopting as final our proposed definition of the term 
``brachytherapy source'' without modification.

VIII. Changes to OPPS Drug Administration Coding and Payment for CY 
2007

A. Background

    From the start of the OPPS until the end of CY 2004, three HCPCS 
codes were used to bill drug administration services provided in the 
hospital outpatient department:
     Q0081 (Infusion therapy, using other than chemotherapeutic 
drugs, per visit)
     Q0083 (Chemotherapy administration by other than infusion 
technique only, per visit)
     Q0084 (Chemotherapy administration by infusion technique 
only, per visit).
    A fourth OPPS drug administration HCPCS code, Q0085 (Administration 
of chemotherapy by both infusion and another route, per visit), was 
active from the beginning of the OPPS through the end of CY 2003.
    Each of these four HCPCS codes mapped to an APC (that is, Q0081 
mapped to APC 0120, Q0083 mapped to APC 0116, Q0084 mapped to APC 0117, 
and Q0085 mapped to APC 0118), and the APC payment rates for these 
codes were made on a per-visit basis. The per-visit payment included 
payment for all hospital resources (except separately payable drugs) 
associated with the drug administration procedures. For CY 2004, we 
discontinued using HCPCS code Q0085 to identify drug administration 
services and moved to a combination of HCPCS codes Q0083 and Q0084 that 
allowed more accurate calculations when determining OPPS payment rates.
    In CY 2005, in response to the recommendations made by commenters 
and the hospital industry, OPPS transitioned to the use of CPT codes 
for drug administration services. These CPT codes allowed for more 
specific reporting of services, especially regarding the number of 
hours for an infusion, and provided consistency in coding between 
Medicare and other payers. However, we did not have any data to revise 
the CY 2005 per-visit APC payment structure for infusion services. In 
order to collect data for future ratesetting purposes, we implemented 
claims processing logic that collapsed payments for drug administration 
services and paid a single APC amount for those services for each 
visit, unless a modifier was used to identify drug administration 
services provided in a separate encounter on the same day. Hospitals 
were instructed to bill all applicable CPT codes for drug 
administration services provided in a hospital outpatient department, 
without regard to whether or not the CPT code would receive a separate 
APC payment during OPPS claims processing.
    While hospitals were just adopting CPT codes for outpatient drug 
administration services in CY 2005, physicians paid under the MPFS were 
using HCPCS G-codes in CY 2005 to report office-based drug 
administration services. These G-codes were developed in anticipation 
of substantial revisions to the drug administration CPT codes by the 
CPT Editorial Panel that were expected for CY 2006.
    In CY 2006, as anticipated, the CPT Editorial Panel revised its 
coding structure for drug administration services, incorporating new 
concepts such as initial, sequential, and concurrent services into a 
structure that previously distinguished services based on type of 
administration (chemotherapy/nonchemotherapy), method of administration 
(injection/infusion/push), and for infusion services, first hour and 
additional hours. For CY 2006, we proposed a crosswalk that mapped the 
expected CY 2006 CPT codes (represented by CY 2005 G-codes used in the 
physician office setting, the closest proxy at the time) to the APC 
payment structure implemented in CY 2005. Our crosswalk was reviewed by 
the APC Panel at both the February and August 2005 meetings, and was 
included in the CY 2006 OPPS proposed rule. During the proposed rule 
comment period, we received a number of comments that prompted several 
revisions to our proposed crosswalk, including the development of 
complex claims processing logic to assign correct payment for certain 
drug administration services that would vary based on other drug 
administration services provided during the same patient visit. These 
revisions were a result of the growing understanding, facilitated by 
the preview of CPT drug administration coding guidelines developed by 
the CPT Editorial Panel, in the hospital community of the multiple 
implications associated with adopting the newly introduced CPT concepts 
of initial, sequential, and concurrent services.
    Upon review of the completed revisions to our proposed CY 2006 
methodology, and following a comprehensive assessment of all public 
comments, we implemented 20 of the 33 CY 2006 drug administration CPT 
codes that did not reflect the concepts of initial, sequential, and 
concurrent services, and we created six new HCPCS C-codes that 
generally paralleled the CY 2005 CPT codes for the same services. We 
chose not to implement the full set of CY 2006 CPT codes because of our 
concerns regarding the interface between the complex claims processing 
logic required for correct payments and hospitals' challenges in 
correctly coding their claims to receive accurate payments for these 
services. In addition, numerous commenters indicated that implementing 
certain CPT codes in a fashion consistent with the code descriptors 
would present hospitals with difficult operational and administrative 
challenges, because concepts integral to the codes were inconsistent 
with the clinical patterns of drug administration services provided in 
hospital outpatient departments. In addition to coding changes, CY 2006 
payment rates for drug administration services were updated based upon 
CY 2004 claims, and we continued the claims processing logic that 
required hospitals providing drug administration services to report all 
applicable drug administration HCPCS codes, despite some codes being 
collapsed into one APC for payment purposes.

B. CY 2007 Drug Administration Coding Changes

    In the CY 2007 OPPS proposed rule, we proposed to continue the CY 
2006 OPPS drug administration coding structure, which combined CPT 
codes with several alphanumeric HCPCS C-codes. However, we solicited 
comments from hospitals regarding their experiences in implementing, 
for purposes of reporting to other payers, the CY 2006 CPT codes 
reflecting the concepts of initial, sequential, and concurrent 
services.
    Due to the discrepancies between APC payments (based on per-visit 
hospital claims data) and per-service CPT/HCPCS coding in CY 2005 and 
CY 2006, we provided special instructions to hospitals regarding the 
appropriate use of modifier 59 in relation to OPPS drug administration 
services in order to

[[Page 68116]]

ensure proper OPPS payments consistent with our claims processing 
logic. As the need no longer existed, for CY 2007 we proposed to 
instruct hospitals to apply modifier 59 to drug administration services 
using the same correct coding principles that they generally use for 
other OPPS services.
    At its August 2006 meeting, the APC Panel recommended that CMS 
recognize only the AMA's CPT codes for outpatient hospital reporting of 
drug administration services in CY 2007. We discuss our response to 
this recommendation along with our response to comments presented 
below.
    We received numerous comments from individual hospitals, health 
systems, university medical centers, physicians, community cancer 
centers, pharmaceutical companies, specialty societies, and various 
healthcare associations, on our proposal to continue with the existing 
CY 2006 OPPS drug administration coding structure for CY 2007, which 
combined CPT codes with several C-codes, as well as comments on the use 
of the CPT codes.
    Comment: A few commenters requested that CMS continue with the 
current CY 2006 coding scheme of using CPT and C-codes for CY 2007, 
while many others requested that CMS use the CPT codes. The commenters 
supportive of our CY 2007 proposal indicated that the CY 2006 CPT drug 
administration codes were not applicable in the hospital setting 
because these codes were created specifically for physician use. 
Several commenters urged CMS to work with the CPT Editorial Panel and 
others to make revisions to the existing CPT codes so they are more 
reflective of hospital services.
    Overall, the vast majority of commenters requested that CMS adopt 
the full set of CPT codes for drug administration services in CY 2007, 
as many hospitals have been using these codes for non-Medicare payers 
for the past year. Several commenters indicated that the use of the CPT 
codes would reduce hospital's current operational burden related to 
charging different payers with different code sets, including the 
burden of maintaining two very different sets of codes for essentially 
the same services. They added that OPPS use of the full set of CPT 
codes would also promote consistency and transparency across sites of 
service and payment systems. The commenters also noted that, contrary 
to last year's substantial concerns regarding the operational aspects 
of implementing these codes, they have now adopted the full CPT code 
set, including full code descriptors and applicable CPT guidelines. 
However, even those commenters favoring adoption of the full set of 
drug administration CPT codes acknowledged that some outstanding 
questions remain regarding billing scenarios using the CPT codes, and 
they requested additional guidance from CMS on these issues. 
Nevertheless, commenters were overwhelmingly in favor of reporting the 
same codes to all payers.
    Response: In the CY 2006 OPPS final rule with comment period (70 FR 
68679), we indicated that we decided not to recognize 13 of the 33 CPT 
drug administration codes in an effort to minimize the administrative 
and operational burden hospitals would have reportedly faced if we had 
adopted all 33 of the CY 2006 drug administration CPT codes. In 
particular, many hospitals expressed concern regarding significant 
administrative problems in implementing the subset of CY 2006 CPT drug 
administration codes that incorporated the concepts of initial, 
sequential, and concurrent. At that time, a substantial number of 
commenters requested that, if CMS were to implement the full set of CY 
2006 CPT codes in the hospital outpatient setting, in order for the 
codes to be applicable to the hospital setting, CMS would need to 
direct hospitals to disregard elements of the code descriptors. As it 
is not our practice to alter CPT codes in order to apply them to a 
particular site of service, we decided not to implement the full set of 
CPT codes at that time. Instead, we developed alphanumeric HCPCS C-
codes for the hospital setting to replace those CY 2006 CPT drug 
administration codes with the problematic concepts of initial, 
sequential, and concurrent.
    During CY 2006, we received anecdotal information related to 
hospitals' experience implementing the full set of CY 2006 CPT codes 
for non-Medicare payers. While yet another transition to new drug 
administration codes was frustrating, these commenters, like commenters 
responding to our CY 2007 proposed rule request for information, noted 
that the operational issues were no longer a primary concern with drug 
administration coding, and they had gained valuable experience over the 
past year reporting these codes to non-Medicare payers. Instead, their 
concern was the time, effort, and administrative costs associated with 
maintaining two code sets for one group of services.
    After considering the recommendation of the APC Panel discussed 
above, and after carefully considering all the public comments received 
on the CY 2007 OPPS proposed rule, we have decided to adopt the full 
set of CPT codes for CY 2007 for use under OPPS. Therefore, we are 
accepting the August 2006 recommendation of the APC Panel to use only 
CPT codes for the reporting of drug administration services in the CY 
2007 OPPS. Table 31 lists the alphanumeric HCPCS codes that were 
created to replace the CPT codes reflecting the concepts of initial, 
sequential, and concurrent, that are deleted effective December 31, 
2006.

Table 31.--Drug Administration C-codes That Will No Longer Be Reportable
                        Under the OPPS in CY 2007
------------------------------------------------------------------------
           HCPCS  Code                       Long description
------------------------------------------------------------------------
C8950...........................  Intravenous infusion for therapy/
                                   diagnosis; up to 1 hour.
C8951...........................  Intravenous infusion for therapy/
                                   diagnosis; each additional hour (List
                                   separately in addition to C8950).
C8952...........................  Therapeutic, prophylactic or
                                   diagnostic injection; intravenous
                                   push of each new substance/drug.
C8953...........................  Chemotherapy administration,
                                   intravenous; push technique.
C8954...........................  Chemotherapy administration,
                                   intravenous; infusion technique, up
                                   to one hour.
C8955...........................  Chemotherapy administration,
                                   intravenous; infusion technique, each
                                   additional hour (List separately in
                                   addition to C8954).
------------------------------------------------------------------------

    Comment: We received a few comments requesting that we retain HCPCS 
code C8957 (Intravenous infusion for therapy/diagnosis; initiation of 
prolonged infusion (more than 8 hours), requiring the use of portable 
or implantable pump), if we finalize a policy to transition to the full 
set of CPT codes for CY 2007. These commenters expressed appreciation 
for CMS' development of the Level II HCPCS code, as there is currently 
no CPT code that describes this service.
    Response: We appreciate the support of commenters in the 
development of this code, and we agree that there is no comparable CPT 
code for this service. As such, we are retaining HCPCS code C8957 for 
use in the CY 2007 OPPS because there is no comparable CPT code 
available to report this service.
    Table 32 lists drug administration HCPCS codes, associated status 
indicators, and CY 2007 APC assignments, where applicable, for CPT 
codes that will be newly recognized under the OPPS for reporting drug

[[Page 68117]]

administration services provided in hospital outpatient departments on 
or after January 1, 2007.

   Table 32.--CY 2007 Newly Recognized Drug Administration CPT Codes*
------------------------------------------------------------------------
   2007 CPT code         2007 description      2007 APC      CY 07 SI
------------------------------------------------------------------------
90760.............  Intravenous Infusion,          0440  S
                     hydration; initial, up
                     to one hour.
90761.............  Intravenous Infusion,          0437  S
                     hydration; each
                     additional hour (list
                     separately in addition
                     to code for primary
                     procedure).
90765.............  Intravenous infusion, for      0440  S
                     therapy, prophylaxis, or
                     diagnosis, (specify
                     substance or drug);
                     initial, up to one hour.
90766.............  Intravenous infusion, for      0437  S
                     therapy, prophylaxis, or
                     diagnosis, (specify
                     substance or drug); each
                     additional hour (List
                     separately in addition
                     to code for primary
                     procedure).
90767.............  Intravenous infusion, for      0437  S
                     therapy, prophylaxis, or
                     diagnosis, (specify
                     substance or drug);
                     additional sequential
                     infusion, up to 1 hour
                     (List separately in
                     addition to code for
                     primary procedure).
90768.............  Intravenous infusion, for        --  N
                     therapy, prophylaxis, or
                     diagnosis, (specify
                     substance or drug);
                     concurrent infusion
                     (List separately in
                     addition to code for
                     primary procedure).
90774.............  Therapeutic, prophylactic      0438  S
                     or diagnostic injection
                     (specify substance or
                     drug); intravenous push,
                     single or initial
                     substance/drug.
90775.............  Therapeutic, prophylactic      0438  S
                     or diagnostic injection
                     (specify substance or
                     drug); each additional
                     sequential intravenous
                     push of a new substance/
                     drug (List separately in
                     addition to code for
                     primary procedure).
96409.............  Chemotherapy                   0439  S
                     administration;
                     intravenous, push
                     technique, single or
                     initial substance/drug.
96411.............  Chemotherapy                   0439  S
                     administration;
                     intravenous, push
                     technique, each
                     additional substance/
                     drug (List separately in
                     addition to code for
                     primary procedure).
96413.............  Chemotherapy                   0441  S
                     administration,
                     intravenous infusion
                     technique; up to 1 hour,
                     single or initial
                     substance/drug.
96415.............  Chemotherapy                   0438  S
                     administration,
                     intravenous infusion
                     technique; each
                     additional hour (List
                     separately in addition
                     to code for primary
                     procedure).
96417.............  Chemotherapy                   0438  S
                     administration,
                     intravenous infusion
                     technique; each
                     additional sequential
                     infusion (different
                     substance/drug), up to 1
                     hour.
------------------------------------------------------------------------
* Current Procedural Terminology (CPT) codes and descriptors are
  copyrighted by the American Medical Association (AMA).

    For CY 2007, we reiterate our CY 2006 final rule statement 
reminding hospitals that they are expected to report all drug 
administration CPT codes in a manner consistent with their descriptors, 
CPT instructions, and correct coding principles. As we have done in the 
past, we will release instructions separately from this final rule with 
comment period that will provide additional OPPS-specific guidance for 
hospital outpatient departments providing drug administration services 
in CY 2007.
    Comment: A few commenters requested that, if CMS implement the full 
set of CPT codes, CMS should also provide hospitals with specific 
instructions on how to bill for CPT codes 90761, 90766, and 96415, as 
their CY 2006 code descriptors included a statement that they were to 
be billed for each hour ``up to 8 hours'' or ``1 to 8 hours.'' The 
commenters requested OPPS billing instructions in the event that 
infusions reported with these codes lasted longer than 8 hours.
    Response: As indicated in Table 32, the CPT Editorial Panel has 
removed the reference to ``up to 8 hours'' and ``1 to 8 hour'' in the 
code descriptors for these three infusion service for CY 2007. 
Therefore, we do not believe any additional guidance is required for 
hospitals at this time.
    Comment: Several commenters requested additional instructions 
regarding the administration of IVIG, hyperimmune IVIG, and DNA- or 
RNA-based therapies. Specifically, the commenters requested that CMS 
identify these items as biological response modifiers and instruct 
hospitals to report chemotherapy administration codes for these 
services in recognition of the significant resources incurred by 
hospitals that provide them.
    Response: CPT instructions for the CY 2006 CPT code set included a 
statement that chemotherapy administration codes are appropriate for 
chemotherapy services but also apply to ``parenteral administration of 
non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic 
agents provided for treatment of noncancer diagnoses (for example, 
cyclophosphamide for auto-immune conditions) or to substances such as 
monocolonal antibody agents, and other biologic response modifiers.'' 
As is our longstanding practice, we defer questions about CPT code 
definitions to the AMA CPT Editorial Panel as they are the creators and 
maintainers of the CPT code set.
    Comment: Several commenters requested that CMS remove various 
National Correct Coding Initiative (CCI) edits related to drug 
administration codes. These commenters expressed frustration about the 
increased administrative burden associated with identifying separate 
instances of drug administration services provided on the same day as a 
procedure that includes a drug administration service.
    Response: We continue to believe that CCI edits for drug 
administration services are appropriate for the hospital outpatient 
department setting. We refer commenters with questions and concerns 
related to particular CCI edits to the National Correct Coding 
Initiative Policy Manual for Medicare Services at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

C. CY 2007 Drug Administration Payment Changes

    Prior to CY 2005, hospitals were reporting per-day drug 
administration codes under the OPPS. These codes did not distinguish 
between the number of services, types of service, or duration of 
services provided. Hospitals received per-day APC payments for 
chemotherapy infusions, non-chemotherapy infusions, and chemotherapy 
other than infusion. With the implementation of CPT codes in CY 2005, 
hospitals began reporting separate codes and associated charges for 
many drug administration services for purposes of the OPPS. The CY 2007 
update process offered us the first opportunity to consider this data 
for purposes of ratesetting.
    For the CY 2007 proposed rule, we explained that we expected codes 
for additional hours of infusion to be reported with codes for the 
first hour of

[[Page 68118]]

infusion. This would result in a substantial set of claims that were 
unusable for ratesetting purposes because multiple services would be 
present on the same bill. (See section II.A. of this preamble for a 
further discussion of multiple bills and our ratesetting methodology). 
In order to use these claims, we explained our process of adding three 
CY 2005 drug administration CPT codes 90781 (Intravenous infusion for 
therapy/diagnosis, administered by physician or under direct 
supervision of physician; each additional hour, up to eight (8) hours); 
96412 (Chemotherapy administration, intravenous; infusion technique, 
one to 8 hours, each additional hour); and 96423 (Chemotherapy 
administration, intra-arterial; infusion technique, one to 8 hours, 
each additional hour) to the bypass list in the CY 2007 proposed rule 
in order to create ``pseudo'' single claims that would be useable for 
OPPS ratesetting purposes. After creation of these ``pseudo'' single 
claims, we applied the standard OPPS methodology to calculate HCPCS 
median costs for these three drug administration codes and mapped their 
respective data to the APCs to which we assigned CY 2005 drug 
administration claims data for purposes of calculating these proposed 
APC median costs.
    As we explained in the CY 2007 proposed rule, bypassing these three 
CPT codes and developing additional ``per unit'' claims provided a 
methodology to calculate median costs for these previously packaged 
drug administration services and to attribute all of their cost data to 
their assigned APCs. However, this methodology allocates all packaging 
on the claim related to drug administration to the associated first 
hour drug administration code. Because these additional hours of 
infusion codes were always reported with other drug administration 
services, we expected that the packaging related to additional hours of 
infusion would be appropriately assigned to the drug administration 
services on the same claim. While we stated our belief that there are 
some packaged costs that are clinically related to the second and 
subsequent hours of infusion, especially for infusions of packaged 
drugs spanning several hours, we were not able for purposes of the CY 
2007 proposed rule to accurately assign representative portions of 
packaged costs to multiple different services due to the limitations of 
our claims data. In the proposed rule, we indicated that we believed 
this proposed methodology took into account all of the packaging on 
claims for drug administration services and provided a reasonable 
framework for developing median costs for drug administration services 
that were often provided in combination with one another.
    After calculating HCPCS code median costs for all drug 
administration services, including injections and antigen therapy 
services, we created a comprehensive set of new APC groupings of CY 
2005 HCPCS codes for drug administration services and based our 
assignments upon hospital resources utilized as reflected in HCPCS code 
median costs and clinical coherence. The result of this analysis was 
the development of six proposed drug administration APC levels based on 
CY 2005 claims data for the CY 2007 OPPS. The proposed structure was 
displayed in Table 30-1 of the CY 2007 OPPS proposed rule, and a 
refined table, reflective of the complete updated CY 2005 hospital 
claims data, is shown below in Table 33.
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    In the proposed rule, we noted that proposed placement of the CY 
2005 drug administration HCPCS codes into the six APC levels followed 
logical,

[[Page 68120]]

clinically coherent principles, and was consistent with both expected 
and observed differences in hospital resource costs, both across levels 
and within each level. For example, the first hour of chemotherapy 
infusion was assigned to Level VI, while additional hours of 
chemotherapy infusion were assigned to Level III. This structure was 
mirrored by the nonchemotherapy codes that showed the first hour of 
nonchemotherapy infusion assigned to Level V, while additional hours of 
nonchemotherapy infusion were assigned to Level II.
    Using this structure as a base, we assigned the CY 2006 OPPS drug 
administration codes to the six-level APC structure based on their 
clinical and expected hospital resource characteristics. This general 
structure was presented to the APC Panel during the March 2006 meeting 
and was our proposed structure for CY 2007. The Panel recommended using 
the bypass methodology as described above for the three additional 
hours of infusion codes to develop their median costs and supported 
separate payment for each additional hour of infusion for CY 2007. In 
the proposed rule, we accepted the APC Panel's recommendation for CY 
2007 to use the proposed structure with the bypass and ``per unit'' 
methodology as described above as it established a drug administration 
payment structure that included a methodology to pay for infusion 
services by the hour.
    Hospitals' cooperation during CY 2005 in reporting all drug 
administration services, whether or not separate payments were made for 
all such services, allowed us to develop robust median costs for 
individual services so that we had sufficient information to propose 
this more specific APC payment structure for drug administration 
services for CY 2007. In the proposed rule, we indicated that we 
believed that this structure would make appropriate payments for the 
hospital resources required to provide drug administration services, as 
we had large numbers of claims for many specific drug administration 
services that revealed significant and differential costs. In 
particular, we noted that using the six-level APC structure should 
allow us to make more accurate payments to hospitals for complex and 
lengthy drug administration services furnished to Medicare 
beneficiaries for many medical conditions, while also providing 
accurate payments for individual services when they were provided 
alone.
    The APC Panel made a number of additional recommendations regarding 
payment for CY 2007 OPPS drug administration services at its August 
2006 meeting in addition to the recommendation, discussed above, that 
CMS adopt the full set of CPT drug administration codes for CY 2007 
OPPS purposes. First, the Panel recommended that if CMS does not 
recognize only the AMA CPT codes for drug administration services for 
CY 2007, CMS should allow hospitals to separately bill and receive 
payments for therapeutic infusions and hydration infusions provided in 
the same encounter. We do not believe that a response to this 
recommendation is required, as we have adopted the full set of CPT 
codes for CY 2007, as discussed above. Second, the Panel recommended 
that CMS make payment for a second or subsequent intravenous push of 
the same drug by instituting a modifier, developing a new HCPCS code 
for the procedure, or implementing another methodology in CY 2007. We 
discuss this recommendation along with comments on this issue in 
further detail below. Third, the Panel recommended that CMS provide 
payment for all intravenous pushes and therapeutic injections for pain 
management and other clinical conditions, regardless of the setting 
(for example, post-operative anesthesia care unit, cardiac 
catheterization laboratory). Again, we discuss this issue in greater 
detail below. Finally, the Panel recommended that CMS provide claims 
analyses of the contribution of packaged costs (considering packaged 
drugs and other packaging) to the median cost of each drug 
administration service.
    During the March and August 2006 meetings of the APC Panel, the 
Panel recommended that we provide additional information specific to 
the costs of packaged items that are represented in drug administration 
APC rates. Specifically, the Panel recommended that:
     CMS provide the Panel with data that indicate the costs of 
packaged drugs that are incorporated into drug administration payment 
rates (March 2006).
     CMS provide claims analysis of the contributions of 
packaged costs (considering packaged drugs and other packaging) to the 
median cost of each drug administration service (August 2006).
    We have performed a preliminary analysis on a subset of CY 2005 
claims data (the data that was used in preparation for the CY 2007 
proposed rule). We intend to provide a more complete analysis based on 
CY 2005 final rule data to the APC Panel during its next meeting; this 
preliminary analysis only serves as a brief summary of our initial 
findings.
    We identified CY 2005 single claims (including ``pseudo'' single 
claims derived from the process detailed in section II.A.1. of this 
preamble) for drug administration services. We used all active CY 2005 
drug administration codes, but excluded the additional hour infusion 
codes (as these hours were not separately payable in CY 2005). In 
addition, their treatment as codes on the bypass list results in no 
packaging being attributed to their ``pseudo'' single claims. Correct 
coding results in their claims always being multiple claims, so we have 
no correctly coded natural single claims for these procedures.
    We identified 16 separate revenue codes where we expected hospitals 
would associate packaged drugs--namely, those revenue codes that are in 
the 250 series (Pharmacy), 260 series (IV Therapy) and 630 series 
(Drugs Require Specific ID). We assumed that, for purposes of this 
analysis, packaged drug costs were included on claims with revenue 
codes listed above or with a drug HCPCS code that in CY 2005 was 
assigned status indicator ``N.'' We also assumed that hospitals 
reported the charges for the packaged drugs on the same claim on which 
they reported the drug administration code, with the same date of 
service.
    We calculated both the median and mean percentages on these single 
and ``pseudo'' single claims for: (1) All packaged costs (drug or not); 
and (2) the subset of packaged drug/pharmacy costs (defined as a code 
for either a drug revenue code cost or a packaged drug HCPCS code). We 
calculated the median costs by calculating the percentages for each 
single bill (including ``pseudo'' singles), arraying them, and 
calculating the 50th percentile of the array. We calculated the mean 
costs by summing the packaged costs of each type for the code and 
dividing each by the sum of all total costs for the code.
    Our initial analysis indicates that, for the highest volume drug 
administration codes, there is a significant amount of drug packaging 
costs on their claims that are used for ratesetting. For example, CPT 
code 90780 for the first hour of nonchemotherapy intravenous infusion 
has a median of 27 percent of packaging of any type and a median of 15 
percent of drug/pharmacy packaging, showing clearly that the cost of 
packaged drugs is reflected in the median for the code. Its respective 
mean amounts are 30 percent and 22 percent. Similarly, for CPT code 
6410, used to report the first hour of chemotherapy intravenous 
infusion, the median amount of packaging of any type is 21 percent, and 
the median amount of drug/pharmacy packaging is 13 percent.

[[Page 68121]]

Its mean amounts are 27 percent and 20 percent respectively. The 
findings are also similar for CPT code 96422 for the first hour of an 
intra-arterial chemotherapy infusion. Its median amount of packaging is 
51 percent, and the median amount of drug/pharmacy packaging is 34 
percent.
    We expect to replicate this study using final rule data for 
presentation to the APC Panel at its first meeting in CY 2007 and to 
present our results in more detail. However, we believe that these 
findings demonstrate that the costs of packaged drugs are reflected in 
the payment for the services with which they are furnished, 
contributing significant costs to establishment of the ultimate drug 
administration services payment rates. We note that in many cases in 
which drug administration codes are billed, Medicare also pays for 
separately paid drugs at ASP+6 percent. Therefore, the total payment 
for the drugs administered in an encounter is the sum of payment for 
separately paid drugs and the portion of the APC payment for drug 
administration services that reflects the packaged costs of drugs/
pharmacy. As mentioned above, we intend to present this study, with 
updated data, to the APC Panel at the next Panel meeting. Therefore, we 
are specifically requesting feedback regarding the usefulness of this 
information to the hospital community.
    We received numerous comments on our payment proposal for drug 
administration services in the CY 2007 OPPS proposed rule.
    Comment: A number of commenters believed that the assignments of CY 
2005 cost data to the six APCs to develop their proposed median costs 
were appropriate. Many commenters were extremely supportive of the CY 
2007 proposal to pay separately for each hour of drug infusion, 
indicating that this payment methodology would provide appropriate 
payment for infusions whose resources varied depending on the length of 
the infusions. Several commenters noted that the current CY 2006 
methodology of paying for drug administration services does not pay 
separately for the second and subsequent hours of drug administration, 
and instead, packages them into payment for the first hour of drug 
administration. One commenter suggested that the packaging of the 
second and subsequent hours for drug administration resulted in 
inadequate reimbursement to hospitals because the payment did not 
reflect the true cost of providing the service, particularly in those 
instances that involved patients who received chemotherapy infusions 
that last 2 or more hours.
    Response: We appreciate the commenters' support for our proposal to 
pay for drug administration services through a six-level APC structure 
for CY 2007, with separate payment to be provided for each hour of drug 
infusion. We remind commenters that our APC rates are based upon median 
costs calculated from historical hospital claims, and hospitals 
reporting multiple hours of infusion service were instructed to report 
the costs for these hours beginning in CY 2005.
    Comment: Several commenters expressed their concerns regarding the 
low proposed payment rates for three chemotherapy administration codes 
described by CPT codes 96440 (Chemotherapy administration into pleural 
cavity, requiring and including thoracentesis); 96445 (Chemotherapy 
administration into peritoneal cavity, requiring and including 
peritoneocentesis); and 96450 (Chemotherapy administration, into CNS 
(e.g., intrathecal), requiring and including spinal puncture). In 
particular, commenters disagreed with our proposed APC assignments for 
CPT codes 96440 and 96445 to APC 0439 (Level IV Drug Administration), 
which had a proposed payment rate of $97.50, and CPT code 96450 to APC 
0441 (Level VI Drug Administration), which had a proposed payment rate 
of $154.31. These commenters reported that the chemotherapy 
administration services described by these three CPT codes are far more 
intensive and require more facility resources than the other drug 
administration services currently assigned to the same APCs.
    The commenters further illustrated that when CPT code 96440 or CPT 
code 96445 is reported, hospitals cannot report separately the surgical 
procedure that is required for the drug administration service, such as 
CPT code 32000 (Thoracentesis, puncture of pleural cavity for 
aspiration, initial or subsequent) or CPT code 49080 
(Peritoneocentesis, abdominal paracentesis, or peritoneal lavage 
(diagnostic or therapeutic); initial). They observed that the proposed 
payments for both surgical procedures were $224.20, and they believed 
that payments for the more extensive drug administration services 
should, therefore, be significantly higher than $224.20. The commenters 
strongly urged CMS to reevaluate the APC assignments for these 
chemotherapy administration codes. One commenter proposed three options 
for how CMS could make changes to the APC assignments for the three CPT 
codes. Specifically, they requested that CMS reassign CPT codes 96440, 
96445, and 96450 to higher paying APCs, create a new APC group with a 
significantly higher payment rate for them, or instruct providers to 
report both the surgical procedures and the related drug administration 
codes as separate line items for the single service.
    Response: We will not instruct hospitals to report CPT codes in a 
manner that is inconsistent with their code descriptors, such as would 
be the case if we asked hospitals to separately report the minor 
surgical procedures required to administer the chemotherapy services, 
when those puncture procedures are included in these drug 
administration code descriptors. We also note that the final median 
costs for these procedures are $160.03 for CPT code 96450 based on 394 
single claims, $37.12 for CPT code 96440 based upon 38 single claims, 
and $61.98 for CPT code 96445 based upon 43 single claims are related 
to the median costs of their proposed APCs. We carefully reviewed all 
the comments received and our CY 2005 claims data, in the context of 
the clinical characteristics of these three services, as well as 
considered the low volume of claims for their single year of hospital 
cost data.
    As we proposed, we continue to believe these services should be 
assigned to drug administration APCs because they are best 
characterized as chemotherapy administration services, albeit with 
special methods of delivery. However, we are reassigning CPT codes 
96440 and 96445 from APC 0439 to APC 0441 (Level VI Drug 
Administration), which has a final median cost of $151.86 as the 
highest paying CY 2007 drug administration APC. If we were to create 
another drug administration APC specifically for these three services, 
its median cost from CY 2005 claims for the special chemotherapy 
administration services would be less than the median cost of APC 0441 
for CY 2007. In addition, based on our CY 2005 claims data from almost 
400 single claims, we believe that the proposed APC assignment for CPT 
code 96450 is accurate and reflects the resource costs associated with 
performing the procedure. We will monitor our claims data in the future 
to see if additional changes are warranted to the APC assignments of 
these chemotherapy services. Therefore, for CY 2007, we are assigning 
CPT codes 96440 and 96445 from APC 0439 to APC 0441, which has a final 
median cost of $151.86, and we are finalizing our proposal without 
modification to assign CPT code 96450 to APC 0441.
    Comment: Several commenters expressed concern about the decrease in

[[Page 68122]]

payment for the ``first hour of infusion'' codes from CY 2006 to their 
proposed CY 2007 rates. They asked that CMS verify that our 
calculations were correct and that the proposed rates were appropriate.
    Response: Based on our CY 2006 payment methodology, we made one 
payment per day for administration of a particular type of infusion, 
regardless of its length, and packaged payment for additional hours of 
infusion of the same type. For example, the CY 2006 payment of $189.04 
for CPT code 96410 (Chemotherapy administration, intravenous; infusion 
technique, up to one hour), reflected a payment for the median 
chemotherapy infusion, regardless of the number of hours of infusion. 
In contrast, for CY 2007 we proposed to pay separately for each hour of 
infusion. In the case of chemotherapy infusions, we proposed to pay 
$154.31 for the first hour, CPT code 96413, and $48.58 for each 
additional hour of infusion, CPT code 96415. We have confirmed that our 
calculations were correct for both the proposed rule and this final 
rule with comment period. The apparent decrease in payment for the 
first hour of infusion is a direct result of our proposal to unpackage 
payment for the additional hours of infusion and provide separate 
payment for each hour as opposed to a per-day payment. Because many 
chemotherapy infusions take place over more than one hour, the payment 
for the first hour appeared to decrease. As discussed earlier in this 
section, in our methodology we also assigned all packaging on the drug 
administration claims to the first hour of infusion codes to allow us 
to use multiple claims for ratesetting. We believe this payment 
methodology will provide more accurate payment to hospitals for the 
specific drug administration services they provide in CY 2007.
    Comment: One commenter expressed concern over the methodology used 
in calculating the CY 2005 median cost for the non-chemotherapy 
intravenous (IV) push injection services, specifically CPT code 90784 
(Therapeutic, prophylactic diagnostic or diagnostic injection (specify 
material injected); intravenous), and requested clarification on our 
methodology. The commenter indicated that providers reported CPT code 
90784 in CY 2005 with multiple units when more than one IV push 
injection was provided, along with a dollar charge reflecting each 
injection. The commenter requested clarification as to whether CMS 
factored the multiple units into its payment rate calculation, and 
whether CMS discarded these claims from the ratesetting process because 
they may have been considered as multiple procedure claims.
    Response: We were unable to use claims reporting multiple units of 
CPT code 90784 on the same date of service for ratesetting, because we 
had no way to attribute the packaging on the claims to the appropriate 
unit of the code. We also had no way of discerning from the CY 2005 
claims whether multiple units of CPT code 90784 were reported for more 
than one intravenous push of the same drug, or multiple pushes of 
different drugs were provided. CPT code 90784 was deleted for CY 2006, 
and replaced by CPT codes 90774 (Therapeutic, prophylactic or 
diagnostic injection (specify substance or drug); intravenous push, 
single or initial substance/drug) and 90775 (Therapeutic, prophylactic 
or diagnostic injection (specify substance or drug); each additional 
sequential intravenous push of a new substance/drug (List separately in 
addition to code for primary procedure)). The situations discussed by 
the commenter would be reported and paid differently in the CY 2007 
OPPS based upon the CY 2007 CPT code descriptors for IV push 
injections. According to our standard OPPS methodology as proposed 
based on median costs from single claims, we used only single claims 
for CPT code 90784 for ratesetting for APC 0438 as shown in Table 33 
above. However, we examined our claims data and found that in over two-
thirds of the cases, hospitals billed only a single unit of CPT code 
90784 per day for an IV push injection. Therefore, we believe that our 
payment rate for the CY 2007 intravenous push injection CPT codes 90774 
(Therapeutic, prophylactic or diagnostic injection (specify substance 
or drug); intravenous push, single or initial substance/drug) and 90775 
(Therapeutic, prophylactic or diagnostic injection (specify substance 
or drug); each additional sequential intravenous push of a new 
substance/drug) through APC 0438 (Level III Drug Administration) is 
appropriate.
    After carefully considering the public comments related to our 
proposed six-level APC structure for drug administration services, we 
are finalizing our proposal with modification to assign all CY 2007 
HCPCS codes for drug administration services to six new drug 
administration APCs, as listed in Table 34, with payment rates based on 
median costs for the APCs as calculated from CY 2005 claims data. We 
note that because our CY 2007 proposal reflected our assignment of CPT 
codes and C-codes to these APCs consistent with our drug administration 
coding proposal for CY 2007, we are finalizing our assignment of the 
newly recognized CPT codes to the APCs where their related C-codes were 
proposed for assignment. In the case of CPT code 90768 (Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or 
drug); concurrent infusion), we are packaging its payment for CY 2007 
to maintain consistency, because concurrent infusions were not 
previously separately reported in the OPPS and their costs are already 
packaged into our CY 2007 payments. We believe that this approach 
provides consistency and will allow us to collect hospital claims data 
over the next two years to assess whether changes to the APC 
assignments for these newly recognized CPT codes should be considered. 
Because the newly recognized CPT codes discriminate among services more 
specifically than the CY 2006 C-codes, as was the case when the OPPS 
transitioned from more general Q-codes to more specific CPT codes for 
the reporting of drug administration services in CY 2005, for a period 
of 2 years drug administration services will be paid based on the costs 
of their predecessor HCPCS codes until updated data are available for 
review.
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[[Page 68124]]

    Comment: In addition to the APC Panel recommendation introduced 
above, a number of commenters requested that CMS pay separately for 
multiple pushes of the same drugs, specifically for a second or 
subsequent IV push performed during the same episode of care, to cover 
the resource costs associated with providing the additional injections 
and drugs. Similar to the recommendation of the APC Panel, commenters 
suggested several options on how CMS could implement such a policy.
    Response: We thank the commenters for their suggestions. However, 
consistent with our policy for reporting intravenous pushes of the same 
drug only once in CY 2006 and consistent with the definition of the CPT 
codes that will be used in CY 2007 to report these services, we will 
continue to provide payment for an intravenous push of each drug only 
once during a hospital encounter in CY 2007. In addition, we do not 
believe it would be appropriate to unbundle procedures by creating a 
new HCPCS code for an element of a service that should be reported with 
existing CPT codes when they are used in the CY 2007 OPPS. We also see 
no need to develop a modifier to identify these situations. We expect 
that hospitals will adjust their charges for the CPT codes used to 
report IV push injections accordingly, based on their experiences with 
providing intravenous injections of drugs in the outpatient setting.
    Therefore, we are not accepting the recommendation of the APC Panel 
to make payment for multiple pushes of the same drug in a single 
hospital encounter.
    Comment: In addition to the APC Panel recommendation introduced 
above, several commenters advised CMS to provide payments for all 
intravenous pushes and therapeutic injections for pain management and 
other clinical conditions, regardless of the setting in which they are 
administered.
    Response: The OPPS is a prospective payment system that provides 
payment for groups of services that are similar both clinically and in 
terms of resource use. We package into payment for each procedure or 
service within an APC group the costs associated with items or services 
that are directly related to performing a procedure or furnishing a 
service. Drug administration services are only paid separately in 
conjunction with many other procedures performed on the same day if 
they are distinct procedural services that are reported in a manner 
consistent with the principles of correct coding. We apply National 
Correct Coding Initiative edits as appropriate to services performed 
under the OPPS. More information regarding these edits may be found in 
the National Correct Coding Initiative Policy Manual for Medicare 
Services as referenced earlier in this section.
    Therefore, we are not accepting the recommendation of the APC Panel 
to pay separately for all intravenous pushes and injections for pain 
management and other clinical conditions. Consistent with our current 
payment policy, in some cases their payment is packaged into payment 
for the associated procedures.
    Comment: Several commenters requested that CMS allow hospitals to 
bill separately and receive payments for the first hour of therapeutic 
infusions and hydration infusions when provided in the same encounter.
    Response: With the use of CPT codes for the reporting of drug 
administration services under the CY 2007 OPPS, hospitals may bill for 
therapeutic drug administration and hydration services provided in the 
same encounter. However, as mentioned above, we expect hospitals to 
adhere to CPT coding instructions and instructions for the use of these 
codes. We do not believe that allowing hospitals to submit claims for, 
and receive separate payment for, the first hour of a therapeutic 
infusion and the first hour of a hydration infusion provided in one 
encounter through a single vascular access site would be consistent 
with CPT coding principles. Therefore, we are not adopting the 
commenters' proposal.
    We note that in the CY 2007 OPPS proposed rule we discussed HCPCS 
code G0332 (Preadministration-related services for intravenous infusion 
of immunoglobulin, per infusion encounter (This service is to be billed 
in conjunction with administration of immunoglobulin)) in this section 
of the preamble. However, for the CY 2007 OPPS final rule with comment 
period, we discuss this code and other issues relating to IVIG in 
section V.B.III. of this preamble.

IX. Hospital Coding and Payments for Visits

A. Background

    Currently, CMS instructs hospitals to use the CY 2006 CPT codes 
used by physicians and listed in Table 35 to report clinic and 
emergency department (ED) visits and critical care services on claims 
paid under the OPPS.

    Table 35.--CY 2006 CPT Codes Used To Report Clinic and Emergency
              Department Visits and Critical Care Services
------------------------------------------------------------------------
                CPT Code                            Descriptor
------------------------------------------------------------------------
                   CPT Evaluation and Management Codes
------------------------------------------------------------------------
99201..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of a new patient
                                          (Level 1).
99202..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of a new patient
                                          (Level 2).
99203..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of a new patient
                                          (Level 3).
99204..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of a new patient
                                          (Level 4).
99205..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of a new patient
                                          (Level 5).
99211..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of an established
                                          patient (Level 1).
99212..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of an established
                                          patient (Level 2).
99213..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of an established
                                          patient (Level 3).
99214..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of an established
                                          patient (Level 4).
99215..................................  Office or other outpatient
                                          visit for the evaluation and
                                          management of an established
                                          patient (Level 5).
99241..................................  Office consultation for a new
                                          or established patient (Level
                                          1).
99242..................................  Office consultation for a new
                                          or established patient (Level
                                          2).
99243..................................  Office consultation for a new
                                          or established patient (Level
                                          3).
99244..................................  Office consultation for a new
                                          or established patient (Level
                                          4).
99245..................................  Office consultation for a new
                                          or established patient (Level
                                          5).
------------------------------------------------------------------------
                  Emergency Department Visit CPT Codes
------------------------------------------------------------------------
99281..................................  Emergency department visit for
                                          the evaluation and management
                                          of a patient (Level 1).
99282..................................  Emergency department visit for
                                          the evaluation and management
                                          of a patient (Level 2).
99283..................................  Emergency department visit for
                                          the evaluation and management
                                          of a patient (Level 3).
99284..................................  Emergency department visit for
                                          the evaluation and management
                                          of a patient (Level 4).
99285..................................  Emergency department visit for
                                          the evaluation and management
                                          of a patient (Level 5).
------------------------------------------------------------------------

[[Page 68125]]

 
                    Critical Care Services CPT Codes
------------------------------------------------------------------------
99291..................................  Critical care, evaluation and
                                          management of the critically
                                          ill or critically injured
                                          patient; first 30-74 minutes.
99292..................................  Each additional 30 minutes.
------------------------------------------------------------------------

    The majority of CPT code descriptors are applicable to both 
physician and facility resources associated with specific services. 
However, we have acknowledged from the beginning of the OPPS that we 
believe that CPT Evaluation and Management (E/M) codes were defined to 
reflect the activities of physicians and do not describe well the range 
and mix of services provided by hospitals during visits of clinic and 
emergency department patients and critical care encounters. Presently, 
CPT indicates that office or other outpatient visit codes are used to 
report E/M services provided in the physician's office or in an 
outpatient or other ambulatory facility. For OPPS purposes, we refer to 
these as clinic visit codes. CPT also indicates that emergency 
department visit codes are used to report E/M services provided in the 
emergency department, defined as an ``organized hospital-based facility 
for the provision of unscheduled episodic services to patients who 
present for immediate medical attention. The facility must be available 
24 hours a day.'' For OPPS purposes, we refer to these as emergency 
department visit codes. CPT defines critical care services as the 
``direct delivery by a physician(s) of medical care for a critically 
ill or critically injured patient.'' It also states that ``critical 
care is usually, but not always, given in a critical care area, such as 
* * * the emergency care facility.''
    In the April 7, 2000 OPPS final rule (65 FR 18434), CMS instructed 
hospitals to report facility resources for clinic and emergency 
department visits using CPT E/M codes and to develop internal hospital 
guidelines to determine what level of visit to report for each patient. 
While awaiting the development of a national set of facility-specific 
codes and guidelines, we have advised that each hospital's internal 
guidelines should follow the intent of the CPT code descriptors, in 
that the guidelines should be designed to reasonably relate the 
intensity of hospital resources to the different levels of effort 
represented by the codes.
    During the January 2002 APC Panel meeting, the APC Panel 
recommended that CMS adopt the American College of Emergency Physicians 
(ACEP) intervention-based guidelines for facility coding of emergency 
department visits and develop guidelines for clinic visits that are 
modeled on the ACEP guidelines.
    In the August 9, 2002 OPPS proposed rule, we proposed 10 new G-
codes (Levels 1-5 Facility Emergency Services and Levels 1-5 Facility 
Clinic Services) for use in the OPPS to report hospital visits. We also 
asked for public comments regarding national guidelines for hospital 
coding of emergency department and clinic visits. We discussed various 
types of models, reflecting on the advantages and disadvantages of 
each. We reviewed in detail the considerations around various discrete 
types of specific guidelines, including guidelines based on staff 
interventions, based upon staff time spent with the patient, based on 
resource intensity point scoring, and based on severity acuity point 
scoring related to patient complexity. We note below our analysis of 
the various models.
1. Guidelines Based on the Number or Type of Staff Interventions
    Under this model, the level of service reported would be based on 
the number and/or type of interventions performed by nursing or 
ancillary staff. In the intervention model, baseline care (including 
registration, triage, initial nursing assessment, periodic vital signs 
as appropriate, simple discharge instructions, and examination room set 
up/clean up) and possibly a single minor intervention (for example, 
suture removal, rapid strep test, or visual acuity) would be reported 
by the lowest level of service. Higher levels of service would be 
reported as the number and/or complexity of staff interventions 
increased.
    The most commonly recommended intervention-based guidelines were 
the facility-coding guidelines developed by the ACEP. The ACEP model 
uses examples of interventions to illustrate appropriate coding. Coders 
extrapolate from these examples to determine the correct level of 
service to report. The ACEP model uses the types of interventions 
rather than the number of interventions to determine the appropriate 
level of service. This means that the single most complex intervention 
determines the level of service, whether it was the only service 
provided (in addition to baseline care), whether other similarly 
complex interventions were also provided, or whether other 
interventions of less complexity were also provided. The intervention 
model is based on emergency department/clinic resource use, is simple, 
reflects the care given to the patient, and does not require additional 
facility documentation. However, we expressed concern that the 
intervention model may provide an incentive to provide unnecessary 
services and that it is susceptible to upcoding. In addition, it is not 
particularly focused on measuring and appropriately reporting a code 
reflecting total hospital resources used in a visit. Furthermore, the 
ACEP model requires extrapolation from a set of examples that could 
make it prone to variability across hospitals.
2. Guidelines Based on the Time Staff Spent With the Patient
    Under this model, the level of service would be determined based on 
the amount of time hospital staff spent with a patient. The underlying 
assumption is that staff time spent with the patient is an appropriate 
proxy for total hospital resource consumption. In this model, if only 
baseline care (as described above) were provided, a Level 1 service 
would be reported. Higher levels of service would be reported based on 
increments of staff time beyond baseline care. For example, Level 2 
could be reported for 11 to 20 minutes beyond baseline care, and Level 
3 could be reported for 21 to 30 minutes beyond baseline care. This 
model is simple, correlates with total hospital resource use, and 
provides an objective standard for all hospitals to follow. However, we 
observed that this model would require additional, potentially 
burdensome documentation of staff time, could provide an incentive to 
work slowly or use less efficient personnel, and has the potential for 
upcoding and gaming.
3. Guidelines Based on a Point System Where a Certain Number of Points 
Are Assigned to Each Staff Intervention Based on the Time, Intensity, 
and Staff Type Required for the Intervention
    In this model, points or weights are assigned to each facility 
service and/or intervention provided to a patient in the clinic or 
emergency department. The level of service is determined by the sum of 
the points for all services/interventions provided. Commenters on the 
August 9, 2002 proposed rule recommended various approaches to a point 
system, including point systems that assigned points based on the 
amount of staff time spent with the

[[Page 68126]]

patient, the number of activities performed during the visit, and a 
combination of patient condition and activities performed. A point 
system would correlate with facility resource consumption and provide 
an objective standard. In addition, it is not as easily gamed because 
time-based interventions can be assigned a set number of points. 
However, we noted that a point system could present a significant 
burden for hospitals in terms of requiring additional, clinically 
unnecessary documentation. Point systems that are complex could require 
dedicated staff to monitor and maintain them.
4. Guidelines Based on Patient Complexity
    Several variations were recommended in comments on the August 9, 
2002 proposed rule, including assignment of levels of service based on 
ICD-9-CM (International Classification of Diseases, Ninth Edition, 
Clinical Modification) diagnosis codes, based on complexity of medical 
decision making, or based on presenting complaint or medical problem. 
The premise for these guideline systems is that many emergency 
departments follow established protocols based on patients' presenting 
complaints and/or diagnoses. Therefore, assigning a level of service 
based on patient diagnosis should correlate with facility resource 
consumption. These systems may require the use of a coding ``grid,'' 
which lists more than 100 examples of patient conditions and diagnoses 
and assigns a level of service to each example. When the patient 
presents with a condition that does not appear on the grid, the coder 
must extrapolate from the grid to the individual patient. We expressed 
concern that these systems are extremely complex, demand significant 
interpretive work on the part of the coder (who may not have clinical 
experience), and are subject to variability across hospitals. While no 
clinically unnecessary documentation would be required because the 
system is based on diagnoses that are already reported on claims, there 
is a significant potential for upcoding and gaming.
    In the August 9, 2002 OPPS proposed rule, we also stated that we 
were concerned about counting separately paid services (for example, 
intravenous infusions, x-rays, electrocardiograms, and laboratory 
tests) as ``interventions'' or including their associated ``staff 
time'' in determining the level of service. We believed that the level 
of service should be determined by resource consumption that is not 
otherwise captured in payments for other separately payable services. 
In the CY 2007 proposed rule, we indicated that we were reconsidering 
this perspective. We discuss this issue further below.
    In the November 1, 2002 OPPS final rule, we specified that we would 
not create new codes to replace existing CPT E/M codes for reporting 
hospital visits until national guidelines have been developed, in 
response to commenters who were concerned about implementing code 
definitions without national guidelines. We noted that an independent 
panel of experts would be an appropriate forum to develop codes and 
guidelines that are simple to understand and implement, and that are 
compliant with HIPAA requirements. We explained that organizations such 
as the American Hospital Associations (AHA) and the American Health 
Information Management Association (AHIMA) had such expertise and would 
be capable of creating hospital visit guidelines and providing ongoing 
education of providers. We also articulated a set of principles that 
any national guidelines for facility visit coding should satisfy, 
including that coding guidelines should be based on facility resources, 
should be clear to facilitate accurate payments and be usable for 
compliance purposes and audits, should meet HIPAA requirements, should 
only require documentation that is clinically necessary for patient 
care, and should not facilitate upcoding or gaming. We stated that the 
distribution of codes should result in a normal curve. We concluded 
that we believed the most appropriate forum for development of code 
definitions and guidelines was an independent expert panel that would 
make recommendations to CMS.
    The AHA and AHIMA originally supported the ACEP model for emergency 
department visit coding, but we expressed concern that the ACEP 
guidelines allowed counting of separately payable services in 
determining a service level, which could result in the double counting 
of hospital resources in establishing visit payment rates and payment 
rates for those separately payable services. Subsequently, on their own 
initiative, the AHA and AHIMA formed an independent expert panel, the 
Hospital Evaluation and Management Coding Panel, comprised of members 
with coding, health information management, documentation, billing, 
nursing, finance, auditing, and medical experience. This panel included 
representatives from the AHA, AHIMA, ACEP, Emergency Nurses 
Association, and American Organization of Nurse Executives. CMS and AMA 
representatives observed the meetings. On June 24, 2003, the AHA and 
AHIMA submitted their recommended guidelines, hereafter referred to as 
the AHA/AHIMA guidelines, for reporting three levels of hospital clinic 
and emergency department visits and a single level of critical care 
services to CMS, with the hope that CMS would publish the guidelines in 
the CY 2004 proposed rule. The AHA and AHIMA acknowledged that 
``continued refinement will be required as in all coding systems. The 
Panel * * * looks forward to working with CMS to incorporate any 
recommendations raised during the public comment period'' (AHA/AHIMA 
guidelines report, page 9). The AHA and AHIMA indicated that the 
guidelines were field-tested several times by panel members at 
different stages of their development. The guidelines are based on an 
intervention model, where the levels are determined by the numbers and 
types of interventions performed by nursing or ancillary hospital 
staff. Higher levels of services are reported as the number and/or 
complexity of staff interventions increase.
    Although we did not publish the guidelines, the AHA and AHIMA 
released the guidelines through their Web sites. Consequently, we 
received numerous comments from providers and associations, some in 
favor and some opposed to the guidelines. We undertook a critical 
review of the recommendations from the AHA and AHIMA and made some 
modifications to the guidelines based on comments we received from 
outside hospitals and associations on the AHA/AHIMA guidelines, 
clinical review, and changing payment policies in the OPPS regarding 
some separately payable services.
    In an attempt to validate the modified AHA/AHIMA guidelines and 
examine the distribution of services that would result from their 
application to hospital clinic and emergency department visits paid 
under the OPPS, we contracted a study that began in September 2004 and 
concluded in September 2005 to retrospectively code, under the modified 
AHA/AHIMA guidelines, hospital visits by reviewing hospital visit 
medical chart documentation gathered through the Comprehensive Error 
Rate Testing (CERT) work. While a review of documentation and 
assignment of visit levels based on the modified AHA/AHIMA guidelines 
to 12,500 clinic and emergency department visits was initially planned, 
the study was terminated after a pilot review of only 750 visits. The 
contractor identified a number of elements in the

[[Page 68127]]

guidelines that were difficult for coders to interpret, poorly defined, 
nonspecific, or regularly unavailable in the medical records. The 
contractor's coders were unable to determine any level for about 25 
percent of the clinic cases and about 20 percent of the emergency cases 
reviewed. The only agreement observed between the levels reported on 
the claims and levels according to the modified AHA/AHIMA guidelines 
was the classification of Level 1 services, where the review supported 
the level on the claims 54-70 percent of the time. In addition, the 
vast majority of the clinic and emergency department visits reviewed 
were assigned to Level 1 during the review. Based on these findings, we 
believed that it was not necessary to review additional records after 
the initial sample. The contractor advised that multiple terms in the 
guidelines required clearer definition and believed that more examples 
would be helpful. Although we believe that all of the visit 
documentation for each case was available for the contractor's review, 
we were unable to determine definitively that this was the case. Thus, 
there is some possibility that the contractor's assignments would have 
differed if additional documentation from the medical records were 
available for the visits. In summary, while testing of the modified 
AHA/AHIMA guidelines was helpful in illuminating areas of the 
guidelines that would benefit from refinement, we were unable to draw 
conclusions about the relationship between the distribution of current 
hospital reporting of visits using CPT E/M codes that are assigned 
according to each hospital's internal guidelines and the distribution 
of coding under the AHA/AHIMA guidelines, nor were we able to 
demonstrate a normal distribution of visit levels under the modified 
AHA/AHIMA guidelines.

B. CY 2007 Proposed and Final Coding Policies

    As discussed above, the majority of all CPT code descriptors are 
applicable to both physician and facility resources associated with 
specific services. However, we believe that CPT E/M codes were defined 
to reflect the activities of physicians and do not describe well the 
range and mix of services provided by hospitals during visits of clinic 
and emergency department patients and critical care encounters. While 
awaiting the development of a national set of facility-specific codes 
and guidelines, we have advised that each hospital's internal 
guidelines should follow the intent of the CPT code descriptors, in 
that the guidelines should be designed to reasonably relate the 
intensity of hospital resources to the different levels of effort 
represented by the codes.
    In the November 1, 2002 OPPS final rule, we specified that we would 
not create new codes to replace existing CPT E/M codes for reporting 
hospital visits until national guidelines have been developed, in 
response to commenters who were concerned about implementing code 
definitions without national guidelines. While we do not yet have a 
formal set of guidelines that we believe may be appropriately applied 
nationally to report different levels of hospital clinic and emergency 
department visits and to report critical care services, we have made 
significant progress in developing potential guidelines. Therefore, in 
the CY 2007 OPPS proposed rule (71 FR 49604-49618), we proposed for CY 
2007 the establishment of HCPCS codes to describe hospital clinic and 
emergency department visits and critical care services. Prior to our 
implementation of national guidelines for the new hospital visit HCPCS 
codes, we proposed that hospitals might continue to use their existing 
internal guidelines to determine the visit levels to be reported with 
these codes. We anticipated that many providers would choose to use 
their existing guidelines for reporting visits with CPT codes. We did 
not expect a substantial workload for a provider that chose to adjust 
its guidelines to reflect our policies.
    We acknowledged that it could be burdensome for providers to bill 
G-codes rather than CPT codes. In this case, because current CPT E/M 
codes do not describe hospital visit resources, we saw no alternative 
other than to create new G-codes. CPT has not yet created clinic and 
emergency department visit and critical care services codes that 
describe hospital resource utilization. It is important to note that G-
codes may be recognized by other payers.
1. Clinic Visits
    For clinic visits, we proposed to establish five new codes to 
replace hospitals' reporting of the CPT clinic visit E/M codes for new 
and established patients and consultations listed in Table 35. 
Providers have been reporting five levels of CPT codes through CY 2006, 
and we believed that it would be fairly easy to crosswalk current 
internal hospital guidelines to these five new codes. Commenters to 
prior rules have stated that the hospital resources used for new and 
established patients to provide a specific level of service are very 
similar, and that it is unnecessary and burdensome from a coding 
perspective to distinguish between the two types of visits. The 
proposed codes are listed in Table 36 below.

   Table 36.--CY 2007 Proposed HCPCS Codes To Be Used To Report Clinic
                                 Visits
------------------------------------------------------------------------
     HCPCS code           Short descriptor           Long descriptor
------------------------------------------------------------------------
Gxxx1..............  Level 1 hosp clinic visit  Level 1 hospital clinic
                                                 visit.
Gxxx2..............  Level 2 hosp clinic visit  Level 2 hospital clinic
                                                 visit.
Gxxx3..............  Level 3 hosp clinic visit  Level 3 hospital clinic
                                                 visit.
Gxxx4..............  Level 4 hosp clinic visit  Level 4 hospital clinic
                                                 visit.
Gxxx5..............  Level 5 hosp clinic visit  Level 5 hospital clinic
                                                 visit.
------------------------------------------------------------------------

    Comment: Although a few commenters were in favor of creating G-
codes for CY 2007, numerous commenters requested that CMS postpone 
creation of G-codes until national guidelines are implemented. Almost 
all of these commenters stated that it would be extremely time 
consuming to train staff in the new coding system, only to retrain them 
1 to 2 years later, when national guidelines were implemented. They 
believed that if national guidelines were established for CY 2007, 
hospitals could justify the time commitment and training expense. They 
added that prior to the establishment of national guidelines, however, 
there is little incentive for hospitals to transition to G-codes. 
Several commenters noted that there would be no benefit of improved 
data if hospitals transitioned to G-codes without guidelines because 
the median cost data captured from the G-codes would parallel current 
data because hospitals would still be using their own internal 
guidelines. It was implicit in many comments that once national 
guidelines are established, hospitals would agree to transition to G-
codes. However, other commenters objected to the G-codes because other 
payors either fail to accept them or do not assign proper payment to 
them. Several commenters suggested that a proposal be submitted to the 
AMA requesting hospital-specific Category I visit codes.
    Response: In response to the numerous comments related to creation 
of G-codes, we are postponing finalizing G-codes for clinic visits 
until national guidelines have been established, when we will again 
consider their possible utility. We are responding to the requests of 
many commenters who stated that it would be too difficult for them to 
first transition to G-codes and then to transition to national 
guidelines

[[Page 68128]]

shortly thereafter. Most commenters indicated a preference for training 
their staff once, for both coding and guidelines, even if it means that 
the training would be significant. In the meantime, as discussed 
further below, we will to continue work to develop national guidelines. 
For CY 2007, providers should continue to use CPT codes to bill for 
clinic visits.
    Comment: Several commenters compared hospital resource cost 
differences between new and established patient visits and discussed 
whether it was necessary to distinguish between the two types of 
visits. The commenters were divided as to whether this distinction was 
necessary or useful. While some commenters stated that it would be 
appropriate to continue using different codes for new and established 
patients because of the observed median cost differences, other 
commenters found it cumbersome to bill a different code for each type 
of visit. One commenter speculated that hospitals often choose a new 
versus an established visit code based upon which code the physician 
bills, instead of choosing a code based on whether the patient is new 
or established at that particular hospital. One commenter suggested 
that the additional resources for new patients be reflected in the 
guidelines, rather than in the coding. Yet another commenter indicated 
that new patients did not necessarily use more hospital resources than 
established patients, and questioned whether both types of codes were 
necessary.
    Response: We initially solicited comment as to whether a 
distinction between new and established visits was necessary because we 
were planning to transition to G-codes and did not want to 
unnecessarily create codes for both new and established visits. 
However, because hospitals will continue to bill CPT codes for CY 2007, 
they must continue to distinguish between new and established patients, 
according to the CPT code descriptor. Therefore, these codes will 
continue to be payable under the OPPS for CY 2007. The AMA defines an 
established patient as ``one who has received professional services 
from the physician or another physician of the same specialty who 
belongs to the same group practice, within the past three years.'' To 
apply this definition to hospital visits, we stated in the April 7, 
2000 final rule with comment period that the meanings of ``new'' and 
``established'' pertain to whether or not the patient already has a 
hospital medical record number. If the patient has a hospital medical 
record that was created within the past 3 years, that patient is 
considered an established patient to the hospital. The same patient 
could be ``new'' to the physician, but an ``established'' patient to 
the hospital. The opposite could be true if the physician has a 
longstanding relationship with the patient, in which case the patient 
would be an ``established'' patient with respect to the physician and a 
``new'' patient to the hospital.
    Because hospitals will be reporting CPT codes for CY 2007, they 
must continue to distinguish between new and established patients, 
according to the CPT code descriptor. However, it may be unnecessary 
for hospitals to report consultation CPT codes if either the new or 
established patient visit code accurately describes the service 
provided. To simplify billing, as many commenters requested, we are now 
considering whether consultation codes are necessary, or if hospitals 
could bill either a new patient visit or an established patient visit, 
instead of a consultation, as appropriate in these cases. We could 
assign status indicator ``B'' to the consultation codes and instruct 
hospitals to bill a new or established visit code. While developing the 
proposal to create G-codes in place of the clinic visit CPT E/M codes 
for CY 2007, we determined that hospitals could report G-code levels 
that reflect their resources used, by applying their guidelines, 
without the need for codes that differentiate among new, established, 
or consultation visits. However, because hospitals will continue to use 
CPT E/M codes for CY 2007, which distinguish between new, established, 
and consultation visits, we invite further input on this issue, 
specifically as to whether the consultation codes are necessary for 
hospitals to report, or whether it would be simpler for hospitals to 
report either a new patient visit or established patient visit, as 
appropriate in each circumstance. We are particularly interested to 
know whether consultation codes are a useful measure of hospital 
resource use under the OPPS, and how they are different, from a 
hospital resource perspective, from new patient visits and established 
patient visits.
    In summary, for CY 2007, providers should continue to use CPT codes 
to bill for clinic visits. The CPT codes for new and established visits 
and consultations will continue to be payable under the OPPS. Prior to 
implementation of national guidelines, we are considering whether it 
would be appropriate for hospitals to bill a new or established E/M 
visit code instead of a consultation code. In the national guidelines, 
we still need to determine whether there should be a distinction 
between new and established visits and consultations. We continue to be 
interested in the opinions of hospital staff and others who are 
familiar with these codes. Further discussion of these codes appears in 
section IX.C. of this preamble.
    Comment: A few commenters requested that CMS clarify whether a 
hospital can bill several clinic visits for services provided to a 
patient who is seen in one clinic by several clinicians on the same 
day, although not at the same time. The commenters stated that, in 
oncology clinics, it is common for patients to have several scheduled 
visits on one day, provided by an oncologist, physicians trained in 
other specialties, therapists, or others, depending on the patients' 
needs. They added that, in some instances, the oncology clinic allows 
the patient to remain in one clinic room, while asking the various 
clinicians to meet the patient in the oncology clinic. One commenter 
noted that the patient usually consumes few hospital resources other 
than use of the clinic room. These commenters also indicated that HCPCS 
code G0175 (Scheduled interdisciplinary team conference (minimum of 
three exclusive of patient care nursing staff) with patient present) 
would only apply if the patient was seen by all the clinicians at the 
same time. According to the commenters, the hospital could bill 
multiple clinic visits if the patient was seen in several different 
clinics on the same day. They believed that the current policy 
penalizes oncology clinics for offering services in an efficient 
manner. One of the commenters requested that CMS change the descriptor 
of G0175 so that it would apply when a patient was treated by several 
clinicians on one day, in one clinic, but not necessarily at the same 
time. The commenter noted that an appropriate payment for the service 
would be at a rate comparable to the critical care payment rate.
    Response: We expect the hospital resources associated with an 
extended clinic visit involving multiple clinicians to be reflected in 
the hospital's internal guidelines used to select the level for 
reporting of the visit. The hospital should bill the clinic visit code 
that most appropriately describes the service provided. We will 
maintain the same code descriptor for G0175 for CY 2007 because we 
believe it is appropriate to pay specifically for interdisciplinary 
team conferences that contribute to well-coordinated, high quality 
care, particularly for patients with severe or complex medical 
conditions. We note that payment for G0175 will be made through APC 
0608 (Level V Clinic

[[Page 68129]]

Visits) at the highest payment level for clinic visits in CY 2007.
2. Emergency Department Visits
    As described above, CPT defines an emergency department as ``an 
organized hospital-based facility for the provision of unscheduled 
episodic services to patients who present for immediate medical 
attention. The facility must be available 24 hours a day.'' Under the 
OPPS, we have restricted the billing of emergency department CPT codes 
to services furnished at facilities that meet this CPT definition. 
Facilities open less than 24 hours a day should not use the emergency 
department codes.
    Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose 
specific obligations on Medicare-participating hospitals and CAHs that 
offer emergency services. These obligations concern individuals who 
come to a hospital's dedicated emergency department (DED) and request 
examination or treatment for medical conditions, and apply to all of 
these individuals, regardless of whether or not they are beneficiaries 
of any program under the Act. Section 1867(h) of the Act specifically 
prohibits a delay in providing required screening or stabilization 
services in order to inquire about the individual's payment method or 
insurance status. Section 1867(d) of the Act provides for the 
imposition of civil monetary penalties on hospitals and physicians 
responsible for failing to meet the provisions listed above. These 
provisions, taken together, are frequently referred to as the Emergency 
Medical Treatment and Labor Act (EMTALA). EMTALA was passed in 1986 as 
part of the Consolidated Omnibus Budget Reconciliation Act of 1985, 
Public Law 99-272 (COBRA).
    Section 489.24 of the EMTALA regulations defines ``dedicated 
emergency department'' as any department or facility of the hospital, 
regardless of whether it is located on or off the main hospital campus, 
that meets at least one of the following requirements: (1) It is 
licensed by the State in which it is located under applicable State law 
as an emergency room or emergency department; (2) It is held out to the 
public (by name, posted signs, advertising, or other means) as a place 
that provides care for emergency medical conditions on an urgent basis 
without requiring a previously scheduled appointment; or (3) During the 
calendar year immediately preceding the calendar year in which a 
determination under the regulations is being made, based on a 
representative sample of patient visits that occurred during that 
calendar year, it provides at least one-third of all of its outpatient 
visits for the treatment of emergency medical conditions on an urgent 
basis without requiring a previously scheduled appointment.
    We believe that every emergency department that meets the CPT 
definition of emergency department also qualifies as a DED under 
EMTALA. However, we are aware that there are some departments or 
facilities of hospitals that meet the definition of a DED under the 
EMTALA regulations but that do not meet the more restrictive CPT 
definition of an emergency department. For example, a hospital 
department or facility that meets the definition of a DED may not be 
available 24 hours a day, 7 days a week. Nevertheless, hospitals with 
such departments or facilities incur EMTALA obligations with respect to 
an individual who presents to the department and requests, or has 
requested on his or her behalf, examination or treatment for an 
emergency medical condition. However, because they do not meet the CPT 
requirements for reporting emergency visit E/M codes, these facilities 
must bill clinic visit codes for the services they furnish. We have no 
way to distinguish in our hospital claims data the costs of visits 
provided in DEDs that do not meet the CPT definition of emergency 
department from the costs of clinic visits.
    Some hospitals have requested that they be permitted to bill 
emergency department visit codes under the OPPS for services furnished 
in a facility that meets the CPT definition for reporting emergency 
department visit E/M codes, except that they are not available 24 hours 
a day. These hospitals believe that their resource costs are more 
similar to those of emergency departments that meet the CPT definition 
than they are to the resource costs of clinics. Representatives of such 
facilities have argued that emergency department visit payments are 
more appropriate, on the grounds that their facilities treat patients 
with emergency conditions whose costs exceed the resources reflected in 
the clinic visit APC payments, even though these emergency departments 
are not available 24 hours per day. In addition, these hospital 
representatives indicated that their facilities have EMTALA obligations 
and should, therefore, be able to receive emergency department visit 
payments. While these emergency departments may provide a broader range 
and intensity of hospital services and require significant resources to 
assure their availability and capabilities in comparison with typical 
hospital outpatient clinics, the fact that they do not operate with all 
capabilities full-time suggests that hospital resources associated with 
visits to emergency departments or facilities available less than 24 
hours a day may not be as great as the resources associated with 
emergency departments or facilities that are available 24 hours a day 
and that fully meet the CPT definition.
    To determine whether visits to emergency departments or facilities 
(referred to as Type B emergency departments) that incur EMTALA 
obligations but do not meet more prescriptive expectations that are 
consistent with the CPT definition of an emergency department (referred 
to as Type A emergency departments) have different resource costs than 
visits to either clinics or Type A emergency departments, we proposed 
in the CY 2007 OPPS proposed rule (71 FR 49608) to establish a set of 
five G-codes for use by all entities that meet the definition of a DED 
under the EMTALA regulations in Sec.  489.24 but that are not Type A 
emergency departments, as described in Table 33 of the proposed rule 
and as finalized as Table 37 below in this final rule with comment 
period. These codes are called ``Type B emergency department visit 
codes.''

[[Page 68130]]



   Table 37.--CY 2007 Final HCPCS Codes To Be Used To Report Emergency
       Department Visits Provided in Type B Emergency Departments
------------------------------------------------------------------------
    HCPCS code         Short descriptor            Long descriptor
------------------------------------------------------------------------
G0380............  Lev 1 hosp type B ED     Level 1 hospital emergency
                    visit.                   department visit provided
                                             in a Type B emergency
                                             department. (The ED must
                                             meet at least one of the
                                             following requirements: (1)
                                             It is licensed by the State
                                             in which it is located
                                             under applicable State law
                                             as an emergency room or
                                             emergency department; (2)
                                             It is held out to the
                                             public (by name, posted
                                             signs, advertising, or
                                             other means) as a place
                                             that provides care for
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment; or (3) During
                                             the calendar year
                                             immediately preceding the
                                             calendar year in which a
                                             determination under this
                                             section is being made,
                                             based on a representative
                                             sample of patient visits
                                             that occurred during that
                                             calendar year, it provides
                                             at least one-third of all
                                             of its outpatient visits
                                             for the treatment of
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment).
G0381............  Lev 2 hosp type B ED     Level 2 hospital emergency
                    visit.                   department visit provided
                                             in a Type B emergency
                                             department. (The ED must
                                             meet at least one of the
                                             following requirements: (1)
                                             It is licensed by the State
                                             in which it is located
                                             under applicable State law
                                             as an emergency room or
                                             emergency department; (2)
                                             It is held out to the
                                             public (by name, posted
                                             signs, advertising, or
                                             other means) as a place
                                             that provides care for
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment; or (3) During
                                             the calendar year
                                             immediately preceding the
                                             calendar year in which a
                                             determination under this
                                             section is being made,
                                             based on a representative
                                             sample of patient visits
                                             that occurred during that
                                             calendar year, it provides
                                             at least one-third of all
                                             of its outpatient visits
                                             for the treatment of
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment).
G0382............  Lev 3 hosp type B ED     Level 3 hospital emergency
                    visit.                   department visit provided
                                             in a Type B emergency
                                             department. (The ED must
                                             meet at least one of the
                                             following requirements: (1)
                                             It is licensed by the State
                                             in which it is located
                                             under applicable State law
                                             as an emergency room or
                                             emergency department; (2)
                                             It is held out to the
                                             public (by name, posted
                                             signs, advertising, or
                                             other means) as a place
                                             that provides care for
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment; or (3) During
                                             the calendar year
                                             immediately preceding the
                                             calendar year in which a
                                             determination under this
                                             section is being made,
                                             based on a representative
                                             sample of patient visits
                                             that occurred during that
                                             calendar year, it provides
                                             at least one-third of all
                                             of its outpatient visits
                                             for the treatment of
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment).
G0384............  Lev 4 hosp type B ED     Level 4 hospital emergency
                    visit.                   department visit provided
                                             in a Type B emergency
                                             department. (The ED must
                                             meet at least one of the
                                             following requirements: (1)
                                             It is licensed by the State
                                             in which it is located
                                             under applicable State law
                                             as an emergency room or
                                             emergency department; (2)
                                             It is held out to the
                                             public (by name, posted
                                             signs, advertising, or
                                             other means) as a place
                                             that provides care for
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment; or (3) During
                                             the calendar year
                                             immediately preceding the
                                             calendar year in which a
                                             determination under this
                                             section is being made,
                                             based on a representative
                                             sample of patient visits
                                             that occurred during that
                                             calendar year, it provides
                                             at least one-third of all
                                             of its outpatient visits
                                             for the treatment of
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment).
G0385............  Lev 5 hosp type B ED     Level 5 hospital emergency
                    visit.                   department visit provided
                                             in a Type B emergency
                                             department. (The ED must
                                             meet at least one of the
                                             following requirements: (1)
                                             It is licensed by the State
                                             in which it is located
                                             under applicable State law
                                             as an emergency room or
                                             emergency department; (2)
                                             It is held out to the
                                             public (by name, posted
                                             signs, advertising, or
                                             other means) as a place
                                             that provides care for
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment; or (3) During
                                             the calendar year
                                             immediately preceding the
                                             calendar year in which a
                                             determination under this
                                             section is being made,
                                             based on a representative
                                             sample of patient visits
                                             that occurred during that
                                             calendar year, it provides
                                             at least one-third of all
                                             of its outpatient visits
                                             for the treatment of
                                             emergency medical
                                             conditions on an urgent
                                             basis without requiring a
                                             previously scheduled
                                             appointment).
------------------------------------------------------------------------

    For CY 2007, we proposed to create five G-codes to be reported by 
the subset of provider-based emergency departments or facilities of the 
hospital, called Type A emergency departments, that are available to 
provide services 24 hours a day, 7 days per week and meet one or both 
of the following requirements related to the EMTALA definition of DED, 
specifically: (1) It is licensed by the State in which it is located 
under the applicable State law as an emergency room or emergency 
department; or (2) It is held out to the public (by name, posted signs, 
advertising, or other means) as a place that provides care for 
emergency medical conditions on an urgent basis without requiring a 
previously scheduled appointment. These codes are called ``Type A 
emergency visit codes'' and were proposed to replace hospitals' current 
reporting of the CPT emergency department visit E/M codes listed in 
Table 35. Our intention was to allow hospital-based emergency 
departments or facilities that are currently appropriately reporting 
CPT emergency department visit E/M codes to bill these new Type A 
emergency department visit codes. We believed that this definition of 
Type A emergency departments would neither narrow nor broaden the group 
of emergency departments or facilities that may bill the Type A 
emergency department visit codes in comparison with those that are 
currently correctly billing CPT emergency department visit E/M codes. 
Rather, our proposal refined and clarified the definition for use in 
the hospital context. We believed that because the concepts employed in 
the definition of a DED for EMTALA purposes are already familiar to

[[Page 68131]]

hospitals, it is appropriate to employ those concepts, rather than the 
concepts employed in the CPT definition of emergency department, for 
purposes of defining these new G-codes. As we have previously noted, 
the CPT codes were defined to reflect the activities of physicians and 
do not always describe well the range and mix of services provided by 
hospitals during visits of emergency department patients. We believed 
that these new codes for reporting emergency department visits to Type 
A emergency departments are more specific to the hospital context. For 
example, one feature that distinguishes Type A hospital emergency 
departments from other departments of the hospital is that Type A 
emergency departments do not generally provide scheduled care, but 
rather regularly operate to provide immediately available unscheduled 
services.
    The new codes that we proposed for CY 2007 are listed in Table 38 
below.

 Table 38.--CY 2007 Proposed HCPCS Codes To Be Used To Report Emergency
       Department Visits Provided in Type A Emergency Departments
------------------------------------------------------------------------
    HCPCS code         Short descriptor            Long descriptor
------------------------------------------------------------------------
Gyyy1............  Lev 1 hosp type A ED     Level 1 hospital emergency
                    visit.                   department visit provided
                                             in a Type A hospital-based
                                             facility or visit
                                             department. (The facility
                                             or department must be open
                                             24 hours a day, 7 days a
                                             week and meet at least one
                                             of the following
                                             requirements: (1) It is
                                             licensed by the State in
                                             which it is located under
                                             applicable State law as an
                                             emergency room or emergency
                                             department; or (2) It is
                                             held out to the public (by
                                             name, posted signs,
                                             advertising, or other
                                             means) as a place that
                                             provides care for emergency
                                             medical conditions on an
                                             urgent basis without
                                             requiring a previously
                                             scheduled appointment).
Gyyy2............  Lev 2 hosp type A ED     Level 2 hospital emergency
                    visit.                   department visit provided
                                             in a Type A hospital-based
                                             facility or visit
                                             department. (The facility
                                             or department must be open
                                             24 hours a day, 7 days a
                                             week and meet at least one
                                             of the following
                                             requirements: (1) It is
                                             licensed by the State in
                                             which it is located under
                                             applicable State law as an
                                             emergency room or emergency
                                             department; or (2) It is
                                             held out to the public (by
                                             name, posted signs,
                                             advertising, or other
                                             means) as a place that
                                             provides care for emergency
                                             medical conditions on an
                                             urgent basis without
                                             requiring a previously
                                             scheduled appointment).
Gyyy3............  Lev 3 hosp type A ED     Level 3 hospital emergency
                    visit.                   department visit provided
                                             in a Type A hospital-based
                                             facility or visit
                                             department. (The facility
                                             or department must be open
                                             24 hours a day, 7 days a
                                             week and meet at least one
                                             of the following
                                             requirements: (1) It is
                                             licensed by the State in
                                             which it is located under
                                             applicable State law as an
                                             emergency room or emergency
                                             department; or (2) It is
                                             held out to the public (by
                                             name, posted signs,
                                             advertising, or other
                                             means) as a place that
                                             provides care for emergency
                                             medical conditions on an
                                             urgent basis without
                                             requiring a previously
                                             scheduled appointment).
Gyyy4............  Lev 4 hosp type A ED     Level 4 hospital emergency
                    visit.                   department visit provided
                                             in a Type A hospital-based
                                             facility or visit
                                             department. (The facility
                                             or department must be open
                                             24 hours a day, 7 days a
                                             week and meet at least one
                                             of the following
                                             requirements: (1) It is
                                             licensed by the State in
                                             which it is located under
                                             applicable State law as an
                                             emergency room or emergency
                                             department; or (2) It is
                                             held out to the public (by
                                             name, posted signs,
                                             advertising, or other
                                             means) as a place that
                                             provides care for emergency
                                             medical conditions on an
                                             urgent basis without
                                             requiring a previously
                                             scheduled appointment).
Gyyy5............  Lev 5 hosp type A ED     Level 5 hospital emergency
                    visit.                   department visit type
                                             provided in a Type A
                                             hospital-based facility or
                                             visit department. (The
                                             facility or department must
                                             be open 24 hours a day, 7
                                             days a week and meet at
                                             least one of the following
                                             requirements: (1) It is
                                             licensed by the State in
                                             which it is located under
                                             applicable State law as an
                                             emergency room or emergency
                                             department; or (2) It is
                                             held out to the public (by
                                             name, posted signs,
                                             advertising, or other
                                             means) as a place that
                                             provides care for emergency
                                             medical conditions on an
                                             urgent basis without
                                             requiring a previously
                                             scheduled appointment).
------------------------------------------------------------------------

    Comment: As discussed above in section IX.B.1. of this preamble 
describing coding for clinic visits, numerous commenters requested that 
CMS postpone adoption of G-codes until CMS has established national 
guidelines. We will not re-summarize or re-respond to those comments in 
this section.
    As to our proposed coding for emergency department visits, the 
majority of commenters agreed with our general distinction between Type 
A and Type B emergency departments. One commenter believed that our 
definition for Type B emergency departments was too broad because many 
urgent care centers would meet the definition of Type B emergency 
department based on the EMTALA criterion that ``During the calendar 
year immediately preceding the calendar year in which a determination 
under this section is being made, based on a representative sample of 
patient visits that occurred during that calendar year, it provides at 
least one-third of all of its outpatient visits for the treatment of 
emergency medical conditions on an urgent basis without requiring a 
previously scheduled appointment.'' This commenter suggested that 
urgent care centers that operated primarily with scheduled appointments 
be required to bill clinic visit codes. Many other commenters stated 
that our Type B emergency department definition was too narrow and 
would apply to only a few emergency departments. One commenter 
requested that CMS add two additional requirements for dedicated Type B 
emergency departments: (1) They must have transfer agreements with 
local and/or regional full service hospitals; and (2) they must have 
the presence of a ``qualified medical person'' (as defined in the 
EMTALA regulations) during operating hours. One commenter requested 
that CMS revise the description of an emergency department by replacing 
the words ``licensed by the State'' with ``authorized or permitted by 
the State'' to allow for States that do not license emergency 
departments.
    Several providers were concerned that CMS has used and is 
continuing to piggyback on the AMA's requirement that an emergency 
department must be open 24 hours a day in order to bill emergency 
department codes. They believed that if CPT codes do not describe 
hospital resources, CMS should not follow the CPT rules when billing 
these CPT codes. One commenter stated that the operating hours of an 
emergency department was irrelevant, and that the resource costs of the 
services provided should instead

[[Page 68132]]

determine selection of the appropriate code. In other words, the 
commenter indicated, if a Type B emergency department that was 
available less than 24 hours a day provided a highly resource-intensive 
service, that Type B emergency department should bill a Type A 
emergency department code and be paid at the Type A emergency 
department rate.
    Several commenters requested that CMS distinguish between Type A 
and Type B emergency departments using a method other than coding, as 
it would be burdensome for providers to choose the correct code. In 
addition, one commenter that specializes in coding indicated that it is 
more appropriate for a code to describe services provided rather than 
the facility type. Several commenters suggested that providers instead 
bill Type B emergency department services under a different revenue 
code than Type A emergency department services.
    Response: In response to the numerous public comments received, and 
as discussed in detail in section IX.B.1. of this preamble on clinic 
visit coding, we are postponing finalizing G-codes for Type A emergency 
department visits until national guidelines have been established, when 
we will again consider their possible utility. For CY 2007, providers 
should continue to use CPT codes to bill for Type A emergency 
department visits. However, we are finalizing the definition of Type A 
emergency departments to distinguish it from Type B emergency 
departments. As stated above, we believe that this definition of Type A 
emergency departments will neither narrow nor broaden the group of 
emergency departments or facilities that may bill the Type A emergency 
department visit codes in comparison to those that are currently 
correctly billing CPT emergency department visit E/M codes. Rather, we 
are refining and clarifying the definition for use in the hospital 
context. A Type A emergency department is a hospital-based facility or 
department that must be open 24 hours a day, 7 days a week and meet at 
least one of the following requirements: (1) It is licensed by the 
State in which it is located under applicable State law as an emergency 
room or emergency department; or (2) It is held out to the public (by 
name, posted signs, advertising, or other means) as a place that 
provides care for emergency medical conditions on an urgent basis 
without requiring a previously scheduled appointment). We were pleased 
that most commenters agreed with our distinction between the two types 
of emergency departments. While we acknowledge the comments that 
requested that we amend the definition of a Type B emergency 
department, we will continue to use the EMTALA definition of a 
dedicated emergency department as defined in 42 CFR 489.24 because, as 
stated above, we believed that because the concepts employed in the 
definition of a DED for EMTALA purposes are already familiar to 
hospitals.
    While we understand the reservations expressed by the commenters 
about the use of G-codes, we believe the creation of G-codes for Type B 
emergency departments is necessary because there currently are no CPT 
codes that fully describe this type of facility. If we were to continue 
instructing Type B emergency departments to bill clinic visit codes, we 
would have no way to track resource costs for Type B emergency 
department visits as distinct from clinic visits. These new G-codes 
will serve as a vehicle to capture median cost and resource differences 
among visits provided by Type A emergency departments, Type B emergency 
departments, and clinics.
    Further, we acknowledge that some providers prefer that we not 
distinguish between providers that are open 24 hours a day and those 
that are not. However, we continue to believe that hours of operation 
significantly impact hospital resource costs. It is necessarily more 
costly to operate a department with full capabilities 24 hours a day 
than to operate with full capabilities 12 hours a day. Emergency 
departments that are open 24 hours a day serve as a crucial safety net 
of our health care system, and we are concerned with ensuring that 
necessary emergency department services are available to Medicare 
beneficiaries. We are concerned that if we allow emergency departments 
that are open less than 24 hours a day to bill Type A emergency 
department codes, the result would be to dilute the median costs 
associated with the provision of services by emergency departments that 
are open 24 hours a day, 7 days a week.
    We note the commenters' concerns that G-codes may not allow 
accurate data collection because services for both Type A and Type B 
emergency department services may be reported under one revenue code. 
However, we expect hospitals to adjust their charges appropriately to 
reflect differences in Type A and Type B emergency departments. The 
current revenue codes do not distinguish between Type A and Type B 
emergency departments. Therefore, to track the resource costs 
differences between clinics, Type A emergency departments, and Type B 
emergency departments, it is necessary to create a new set of codes to 
be billed by Type B emergency departments. We will consider whether 
further instructions are necessary in the future to enhance our data 
collection.
    Comment: Several commenters requested that CMS clarify whether Type 
A emergency department codes, Type B emergency department codes, or 
clinic visit codes apply in specific situations. One questioned whether 
a Type A emergency department that has a separate adjacent space that 
is organizationally part of the Type A emergency department, but treats 
less severe patients and is often closed at night, would be eligible to 
bill the Type A emergency department visit codes. The commenter 
clarified that the primary emergency area is fully staffed 24 hours a 
day. Several commenters questioned whether services provided at a 
satellite emergency department that is open less than 24 hours a day, 
located at a different location than the main campus, could bill the 
Type A emergency department visit codes. Again the commenter clarified 
that the primary emergency department was available 24 hours a day. Yet 
another commenter requested clarification about a Type A emergency 
department that operated subunits or locations within a Type A 
emergency department, that are closed part of the day or night, based 
on fluctuations in patient loads. This commenter noted that these 
subunits are sometimes referred to as ``Fast Track areas.''
    Response: We are aware that hospitals operate many types of 
facilities which they view in aggregate as an integrated healthcare 
system. For purposes of determining EMTALA obligations, under Sec.  
489.24(b) of the regulations, each hospital is evaluated individually 
to determine its own particular obligations. As we have discussed 
previously, hospital facilities or departments of the hospital that 
meet the definition of a dedicated emergency department consistent with 
the EMTALA regulations may bill Type A emergency department codes (CPT 
emergency department visit codes) or Type B emergency department codes 
(HCPCS G-codes), depending on whether or not the dedicated emergency 
department meets the definition of a Type A emergency department, which 
includes operating 24 hours per day, 7 days a week. For purposes of 
determining whether to bill Type A or Type B emergency department 
codes, each hospital must be evaluated individually and should make a 
decision specific to each area of the hospital to determine which codes

[[Page 68133]]

would be appropriate. Where a hospital maintains a separately 
identifiable area or part of a facility which does not operate on the 
same schedule (that is, 24 hours per day, 7 days a week) as its 
emergency department, that area or facility would not be considered an 
integral part of the emergency department that operates 24 hours per 
day, 7 days a week for purposes of determining its emergency department 
type for reporting emergency visit services. Instead, the facility or 
area would be evaluated separately to determine whether it is a Type A 
emergency department, Type B emergency department, or clinic. We would 
expect the hospital providing services in such facilities or areas to 
evaluate the status of those areas and bill accordingly. In general, it 
is not appropriate to consider a satellite emergency department or an 
area of the emergency department as if it were available 24 hours a day 
simply because the main emergency department is available 24 hours a 
day. It may be appropriate for a Type A emergency department to ``carve 
out'' portions of the emergency department that are not available 24 
hours a day, where visits would be more appropriately billed with Type 
B emergency department codes.
    For CY 2007, we are finalizing our proposal with modification. We 
are not adopting the G-codes in Table 38 for Type A emergency 
departments, but we are adopting the G-codes in Table 37 for Type B 
emergency departments.
3. Critical Care Services
    For critical care services, we proposed in the CY 2007 OPPS 
proposed rule (71 FR 49610) to create two new codes to replace 
hospitals' reporting of the CPT E/M critical care codes listed in Table 
35 above. Providers have been reporting two CPT codes through CY 2006, 
and we believed that it would be fairly easy to crosswalk current 
internal hospital guidelines to these two new codes. The proposed new 
codes are listed in Table 39 below.

  Table 39.--CY 2007 Proposed HCPCS Codes To Be Used To Report Critical
                              Care Services
------------------------------------------------------------------------
    HCPCS code         Short descriptor            Long descriptor
------------------------------------------------------------------------
Gccc1............  Hosp critical care, 30-  Hospital critical care
                    74 min.                  services, first 30-74
                                             minutes.
Gccc2............  Hosp critical care, add  Hospital critical care
                    30 min.                  services, each additional
                                             30 minutes.
------------------------------------------------------------------------

    Comment: In addition to the many comments we received about G-codes 
in general, we received many comments on the proposed G-codes specific 
to critical care. Most comments fell under one of two categories: (1) 
Remove the minimum time requirement for critical care services; or (2) 
create one G-code for critical care without trauma activation and one 
G-code for critical care with trauma activation.
    Many commenters requested that CMS allow hospitals to bill critical 
care without a minimum time requirement. The commenters indicated that 
it was extremely difficult to measure time while providing critical 
care services because of the intensity of the services provided. These 
commenters also indicated that it is easier and more appropriate to use 
time when measuring physician resources rather than facility resources. 
They did not believe that time is an appropriate proxy for measuring 
hospital resource utilization when providing hospital critical care 
services because the hospital may have its highest resource use in the 
first 10 minutes of critical care, much earlier than the 30-minute 
minimum required in the code descriptor. However, because the proposed 
G-code indicates a minimum of 30 minutes of critical care services 
before the critical care code can be billed, the commenters indicated 
that the hospital would not be able to bill for the critical care 
services it provided. In case we still continued to require a 30-minute 
minimum, the commenters asked us to clarify how a hospital should count 
time. They asked: Does it start when the patient is admitted? Should 
each provider of care measure his own minutes, after which the hospital 
would add together all the minutes from all the providers involved? In 
addition, several commenters referenced page 18452 of the April 7, 2000 
final rule preamble language, which has been interpreted by commenters 
to mean that the 30-minute minimum for critical care does not apply 
under the OPPS. One commenter requested that CMS remove the 30-minute 
minimum requirement because it creates a disincentive to provide 
critical care services in an efficient manner. Several commenters 
indicated that critical care should be the highest level visit code, 
regardless of time. One commenter suggested that critical care be paid 
at a flat rate, rather than involving time. Another commenter indicated 
that its State Medicaid agency did not accept critical care as a 
payable service and would only pay for the highest level emergency 
department visit code.
    Many commenters requested CMS to finalize the proposal to create G-
codes for critical care, but that, in doing so, CMS create one G-code 
for critical care without trauma activation and one G-code for critical 
care associated with trauma activation. They also requested that CMS 
pay differentially for critical care provided with and without trauma 
activation. The commenters suggested that critical care services with 
trauma activation require a significantly higher level of hospital 
resources than critical care services alone. In particular, one 
commenter who made a presentation during the August 2006 APC Panel 
meeting suggested that CMS use revenue codes in the 68x series reported 
on the same date as a critical care service to determine whether a 
trauma response was activated in association with critical care 
services in order to facilitate selection of appropriate claims to 
establish differential payment rates for critical care services with 
and without trauma activation. The APC Panel recommended that CMS 
analyze cost data to determine if additional payment for trauma 
response was appropriate.
    Response: We responded to the general comments regarding the use of 
G-codes in section IX.B.1. of this preamble on clinic visit coding. 
Under this response, we address the comments specific to critical care 
coding.
    First, we would like to respond to the apparent confusion 
concerning the April 7, 2000 response to a comment that we pay 
separately instead of packaging CPT code 99292 (each additional 30 
minutes of critical care time). Apparently, many commenters 
misinterpreted the preamble language in that final rule and believed 
that it was not necessary to apply a 30-minute minimum before billing a 
critical care code. However, in response to a request to pay separately 
for CPT code 99292,

[[Page 68134]]

we responded that ``We do not believe that paying hospitals for 
incremental time as critical care would better reflect facility 
resources. The most resource-intensive period for the hospital is 
generally the first hour of critical care. In addition, we believe it 
would be burdensome for hospitals to keep track of minutes for billing 
purposes. Therefore, we will pay for critical care as the most 
resource-intensive visit possible as defined by CPT code 99291.'' In 
this context, it is clear that our response did not deal with the 
application of a 30-minute minimum time in the OPPS. Rather, our 
response dealt only with the issue involved; the packaging of payment 
for CPT code 99292. Specifically, we indicated that we package CPT code 
99292 because it is burdensome for hospitals to track each additional 
30-minute increment of time. Instead of requiring this tracking of all 
minutes of critical care services, we package payment for CPT code 
99292 into the payment for CPT code 99291. Our response did not 
indicate that the 30-minute minimum requirement does not apply to CPT 
code 99291. In fact, the 30-minute minimum requirement has always 
applied and will continue to apply for CY 2007 and beyond. As is 
currently the case, the hospital can bill the appropriate clinic or 
emergency department visit code if fewer than 30 minutes of critical 
care is provided. We may provide more specific billing guidance at a 
later point in time. As described below, for CY 2007, clinic and 
emergency department visits will be paid at five levels, rather than 
three levels, which will ensure more accurate payments for these 
visits. Five payment levels will increase the payment rates for the 
highest level clinic and emergency department visits, which should 
benefit hospitals that provide these high-level services.
    In response to the commenters who requested that we pay 
differentially for critical care associated with trauma response, as 
well as the recommendation of the APC Panel, we performed several 
studies to determine whether critical care associated with trauma 
response was costlier than critical care without trauma response. As 
suggested by the commenter, we used revenue codes in the 68x series 
reported on the same date as a critical care service to determine 
whether a trauma response was activated in association with critical 
care services in order to facilitate selection of appropriate claims. 
There are specific National Uniform Billing Committee guidelines 
related to the reporting of trauma revenue codes in the 68x series, 
first implemented in October 2002. The revenue codes series 68x can 
only be used by trauma centers/hospitals as licensed or designated by 
the state or local government authority authorized to do so, or as 
verified by the American College of Surgeons. Different subcategory 
codes are reported by the designated Level 1-4 hospital trauma centers. 
Only patients for whom there has been prehospital notification based on 
triage information by prehospital caregivers, who meet either local, 
state, or American College of Surgeons field triage criteria, or are 
delivered by interhospital transfers, and are given the appropriate 
team response can be billed a trauma activation charge.
    We analyzed CY 2005 claims for critical care services, dividing 
claims into two groups: Those with trauma revenue code 68x on the same 
date of service as CPT code 99291 for the first period of critical care 
and those without trauma revenue code 68x on the same date of service 
as the critical care code. The median cost for critical care with a 
trauma revenue code charge is approximately $894, and the median cost 
for claims for critical care without a trauma revenue code charge is 
approximately $403. The proposed CY 2007 median cost for critical care 
was $495.
    We further reviewed the list of providers who billed critical care 
with a trauma revenue code. We noted that of all the 2,200 hospitals 
that billed a critical care code during CY 2005, less than 2 percent of 
these hospitals billed a trauma revenue code on the same date of 
service as CPT code 99291 one or more times on an OPPS claim. In 
addition, many of the hospitals that billed critical care with a trauma 
revenue code also billed critical care without a trauma revenue code. 
We further investigated whether providers that billed critical care 
with a trauma revenue code on the same date of service had higher 
median costs in general than providers that billed critical care 
without a trauma revenue code. We re-ran the median cost of critical 
care without a trauma revenue code on the same date of service using 
only claims from the subset of providers that had billed critical care 
with revenue code 68x to determine if it was different than the $403 
median cost that was calculated using all providers. Our results showed 
that providers that billed critical care with revenue code 68x had very 
similar critical care resource costs to other hospitals.
    Therefore, for CY 2007, because we see meaningful cost differences 
between critical care when billed with and without trauma activation, 
we will pay differentially for critical care when there is trauma 
activation associated with the critical care and when there is no 
trauma activation. This will improve the accuracy of payments as 
related to resource use. Trauma centers provide important local and 
regional health services and serve valuable roles in their communities 
through their well-developed emergency capabilities.
    In response to commenters' concern about G-codes, we will continue 
to instruct providers to bill CPT codes 99291 and 99292 for critical 
care. In addition, we are creating one new G-code, G0390 (Trauma 
response team activation associated with hospital critical care 
service), effective January 1, 2007, which is assigned to APC 0618 
(Critical Care with Trauma Response), with a median cost of $491.66. 
When critical care is provided without trauma activation, the hospital 
will bill CPT code 99291 (and 99292, if appropriate) as usual, and 
receive payment for APC 0617 (Critical Care), which has a median cost 
of $402.67, calculated from that subset of single claims for CPT code 
99291 without revenue code 68x reported on the same day. If trauma 
activation occurs under the circumstances described by the National 
Uniform Billing Committee guidelines that would permit reporting a 
charge under 68x, the hospital may also bill one unit of G-code G0390, 
reported with revenue code 68x on the same date of service, thereby 
paying the hospital $491.66 under APC 0618. The CY 2007 median cost for 
APC 0618 was established based on the difference in median costs from 
the two subsets of single claims for CPT code 99291 representing the 
reporting of critical care services with and without revenue code 68x 
reported on the same day. The OCE will edit to ensure that G0390 
appears with revenue code 68x on the same date of service and that only 
one unit of G0390 is billed. We believe that trauma activation is a 
one-time occurrence in association with critical care services, and 
therefore, we will only pay for one unit of G0390 per day. CPT code 
99292 remains packaged for CY 2007. We will monitor usage of the CPT 
codes for critical care services and the new G-code to ensure that 
their utilization remains at anticipated levels.
    For CY 2007, we are not adopting the proposed HCPCS G-codes in 
Table 39 for critical care services but we are adopting one new G-code 
(G0390) for trauma activation and response in association with critical 
care services.

C. CY 2007 Payment Policy

    Since the implementation of the OPPS, outpatient visits provided by

[[Page 68135]]

hospitals have been paid at three payment levels for both clinic and 
emergency department visits, even though hospitals have been reporting 
five resource-based coding levels of clinic and emergency department 
visits using CPT E/M codes. Critical care services have been paid at 
one level, with separate payment for the first 30 to 74 minutes of care 
and bundling of payment for all additional 30 minute increments of 
critical care services into payment for the first 30-74 minutes. If the 
critical care service is less than 30 minutes in duration, it is to be 
billed as either a clinic visit or an emergency department visit CPT 
code. Because the three payment rates for clinic and emergency 
department visits are based on five levels of CPT codes as listed in 
Table 40, in general the two lowest levels of CPT codes (1 and 2) have 
been assigned to the low-level visit APC and the two highest levels of 
CPT codes (4 and 5) have been assigned to the high-level visit APC, 
with the single middle CPT level CPT code (3) assigned to the mid-level 
visit APC. Hospital claims data indicate that the cost of providing a 
visit of the same level is generally significantly higher for emergency 
department visits in comparison with clinic visits, with the 
differential increasing at higher levels of services.
    Based upon CY 2005 claims data processed through December 31, 2005, 
the median costs of clinic visit, emergency department visit, and 
critical care APCs as configured for CY 2006 are listed below.

  Table 40.--Median Costs of Clinic and Emergency Department Visit and
              Critical Care APCs as Configured for CY 2006
------------------------------------------------------------------------
                                                   Levels of CPT Codes
           APC Title               APC Median        Assigned to APC
------------------------------------------------------------------------
                              Clinic Visits
------------------------------------------------------------------------
Low Level Clinic Visits........          $53.14  Level 1 Clinic Visit,
                                                  Level 2 Clinic Visit.
Mid Level Clinic Visits........           61.89  Level 3 Clinic Clinic
                                                  Visit.
High Level Clinic Visits.......           89.09  Level 4 Clinic Visit,
                                                  Level 5 Clinic Visit.
------------------------------------------------------------------------
                       Emergency Department Visits
------------------------------------------------------------------------
Low Level Emergency Visits.....          $74.44  Level 1 ED Visit, Level
                                                  2 ED Visit.
Mid Level Emergency Visits.....          129.25  Level 3 ED Visit.
High Level Emergency Vists.....          230.52  Level 4 ED Visit, Level
                                                  5 ED Visit.
------------------------------------------------------------------------
                         Critical Care Services
------------------------------------------------------------------------
Critical Care..................         $478.04  Critical care, first
                                                  hour.
------------------------------------------------------------------------

    However, historical hospitals claims data have generally reflected 
significantly different median costs for the two levels of services 
assigned to the low and high level visit APCs. While the median costs 
of these services do not violate the 2 times rule within their assigned 
APCs, this may not be the most accurate method of payment for these 
very common hospital levels of visits which clearly demonstrate 
differential hospital resources. In particular, because of the 
relatively low volume of the highest levels of services in the clinic 
and emergency department, our payment rates may be especially low. 
Therefore, we proposed to create five payment levels for clinic and 
emergency department visits and one payment level for critical care 
services.
    As discussed in section IX.B. of this preamble, we are not adopting 
our proposal to replace all visit and critical care E/M CPT codes with 
G-codes, but we are creating five new G-codes to describe Type B 
emergency department visits and one new G-code to describe critical 
care services associated with trauma activation and response in 
association with critical care services.
    In the proposed rule, to determine appropriate payment rates for 
the proposed new G-codes, we mapped the data from the CY 2005 CPT E/M 
codes and other HCPCS codes currently assigned to the clinic visit APCs 
to 11 new APCs, 5 for clinic visits, 5 for emergency department visits, 
and 1 for critical care services as shown in Table 41 to develop median 
costs for these APCs. We mapped the CPT E/M codes and other HCPCS codes 
to the new APCs based on median costs and clinical considerations. The 
table, which is reprinted below, is relevant for calculating median 
costs at five payment levels, regardless of whether hospitals use CPT 
codes or G-codes.
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    In the case of the CPT E/M codes for emergency department visits, 
the assignment of data for the proposed rule from five levels of coding 
to five levels

[[Page 68137]]

of payment was straightforward. However, in some cases of the data for 
CPT clinic visit E/M codes, we assigned a code to an appropriate clinic 
visit APC level based upon resource and clinical homogeneity 
considerations, and that APC assignment did not correspond to the visit 
level described by the code. For example, CPT 99213 is a Level 3 clinic 
visit code for an established patient, which would seem to logically 
map to the Level 3 Clinic Visit APC. However, because CPT 99213 has a 
median cost of $60.70, it maps more appropriately to the Level 2 Clinic 
Visit APC, which has an overall median cost of $60.13. In general, CPT 
codes for established patient visits had lower median costs than new 
patient visit or consultation codes of the same E/M level, and that 
variability was reflected in their respective proposed APC data 
assignments for CY 2007.
    For CY 2007, we proposed to assign the five new Type A emergency 
department visit codes for services provided in a Type A emergency 
department to the five new Emergency Visit APCs, 0609, 0613, 0614, 
0615, and 0616.
    For CY 2007, we proposed to assign the five new Type B emergency 
department visit codes for services provided in a Type B emergency 
department to the five new Clinic Visit APCs, 0604, 0605, 0606, 0607, 
and 0608. This payment policy for Type B emergency department visits is 
similar to our current policy which requires services furnished in 
emergency departments that have an EMTALA obligation but do not meet 
the CPT definition of emergency department to be reported using CPT 
clinic visit E/M codes, resulting in payments based upon clinic visit 
APCs. As mentioned above, CPT and CMS require an emergency department 
to be open 24 hours per day in order for it to be eligible to bill 
emergency department E/M codes. While maintaining the same payment 
policy for Type B emergency department visits in CY 2007, the reporting 
of specific G-codes for emergency department visits provided in Type B 
emergency departments will permit us to specifically collect and 
analyze the hospital resource costs of visits to these facilities in 
order to determine in the future whether a proposal of an alternative 
payment policy may be warranted. The OPPS rulemaking cycle for CY 2009 
will be the first year that we will have cost data for these new Type B 
emergency department HCPCS codes available for analysis. This approach 
to more refined data collection is similar to our approach to drug 
administration services under the OPPS over the past several years. We 
collected hospital claims data for specific detailed services using CPT 
and HCPCS codes for CYs 2005 and 2006, while making payments based on 
claims data available to us for the less specific HCPCS codes billed by 
hospitals prior to CY 2005. We recognize that reporting specific drug 
administration services for which hospitals received no separate or 
additional payments created some additional administrative burden on 
hospitals for a period of time, but the resource information collected 
through the claims submissions has been critical to the development of 
our proposal of more refined drug administration payment policies. The 
hospital claims data based upon the CY 2005 drug administration coding 
structure now form the foundation of our final CY 2007 policy for drug 
administration services as described in section VIII. of the preamble 
of this final rule with comment period.
    In the proposed rule, we noted that we were particularly concerned 
with ensuring that necessary emergency department services are 
available to rural Medicare beneficiaries. We recognize that rural 
emergency departments may be disproportionately likely to offer 
essential emergency department services less than 24 hours per day, 7 
days a week because of the limited demand for those services and the 
high costs and inefficiencies associated with providing full emergency 
department availability during times when few patients present for 
emergency care. We believe that our OPPS payment policies for Type A 
and Type B emergency department visits should support the ability of 
hospitals to provide their communities with essential and appropriate 
emergency department services efficiently and effectively. We also 
believe that the payment policies should present no payment incentive 
for hospitals to provide necessary emergency services less than 24 
hours per day, 7 days per week, which could result in limited access to 
emergency services for Medicare beneficiaries, thereby leading to 
adverse effects on their health.
    Comment: The commenters were divided as to whether to continue with 
three payment levels or to move to five payment levels for clinic and 
emergency department visits. Several commenters noted that five payment 
levels is better because it is similar to the payment structure of 
other payors, while others noted that three levels was more appropriate 
because it is difficult to distinguish among four or five levels. 
Another commenter opposed creation of five levels because its 
experience has shown that providers tend to choose the middle level 
automatically. One commenter preferred three levels to five levels to 
distinguish it from physician coding. Several commenters requested that 
CMS continue paying at three payment levels until CMS established 
national guidelines. These commenters also requested that CMS not 
transition to G-codes until national guidelines were established. They 
preferred to maintain the status quo until national guidelines were 
established, at which point they believed it would be more appropriate 
to also revise the coding and payment structure. The commenters 
believed that it would be simpler to make the changes all at once, 
rather than making incremental changes, leading up to the establishment 
of national guidelines.
    Several commenters favored moving to five payment levels before 
national guidelines were established, and encouraged CMS to finalize 
the number of payment levels before continuing work on national 
guidelines. The commenters believed that, if the cost data showed that 
five payment levels would lead to a more accurate distribution of 
payment, they were in favor of the change.
    While most comments favored the distinction between Type A and Type 
B emergency departments, several commenters believed that Type B 
emergency department visits should be paid at Type A emergency 
department rates, rather than clinic visit rates. The commenters 
believed that, although these facilities were open less than 24 hours a 
day, the services provided more closely resemble emergency department 
services than clinic services, and therefore, their resource costs were 
higher than clinics. Other commenters believed it was appropriate and 
reasonable to pay for Type B emergency departments at clinic visit 
rates until cost data was collected. One commenter was concerned that 
``unfettered proliferation of less than full-service emergency 
departments could reduce access for many individuals who need emergency 
care after hours when Type B emergency departments are closed. We do 
not want these facilities to have financial incentives to locate in 
areas where the population is more affluent and largely insured, 
leaving full-service hospital emergency departments with an even larger 
financial burden to care for the uninsured and underinsured after 
hours.'' The commenter favored the distinction between the two types of 
emergency departments, but believed the costs of Type B emergency 
departments is closer to the cost of Type

[[Page 68138]]

A emergency department visits than clinic visits. The commenter was 
unsure of the direct impact this payment policy will have on Type B 
emergency departments, recognizing that these facilities improve 
patient access to emergency care. In particular, the commenter wondered 
how many hospital-based Type B emergency departments exist and how many 
of them are currently billing at emergency department rates. One 
commenter noted that emergency departments are suffering financially, 
and that CMS should pay them at higher rates to ensure continued 
access. Several commenters suggested that CMS pay Type B emergency 
departments at a rate somewhere in between the Type A emergency 
department rates and clinic visit rates until complete cost data are 
collected.
    Several commenters responded to our concern that rural hospitals 
may be disproportionately likely to offer essential emergency 
department services less than 24 hours per day, 7 days a week. 
Specifically, one commenter confirmed through conversations with State 
associations and hospitals that few emergency departments are open less 
than 24 hours a day. In particular, the commenter indicated many rural 
hospitals are designated as CAHs, for which the Medicare CAH conditions 
of participation require that emergency services are available 24 hours 
a day. While the commenter had heard of a few emergency departments 
that were open less than 24 hours a day, it did not believe that any 
rural emergency departments were open less than 24 hours a day.
    One commenter suggested that CMS adjust the copayments so that the 
Level 1 clinic copayment becomes significantly less than the Level 1 
emergency department visit, to provide an incentive for Medicare 
beneficiaries to receive care in the most cost-efficient setting.
    As discussed in section IX.B.3. of this preamble on coding, we 
received a significant number of comments regarding payment for 
critical care services associated with trauma activation. We summarized 
and responded to those comments in that section.
    Response: While we acknowledge the concern of several commenters 
that it is best to remain at status quo until national guidelines are 
developed, we continue to believe that five payment levels are now 
appropriate for both clinic and emergency department visits based on 
median cost data. This will allow us to more accurately distribute 
clinic and emergency department payments, as also noted by several 
commenters.
    Five payment levels will increase the payment rates for the highest 
level clinic and emergency department visits, which will benefit 
hospitals that provide these high-level services. In addition, we do 
not anticipate that hospitals will need to update their internal 
guidelines to reflect this change, as it affects payment, not coding. 
While we have heard anecdotally that some hospitals only bill level 1, 
level 3, and level 5 clinic and emergency department visit CPT codes to 
simplify their internal coding, our data indicates a fairly normal 
distribution, suggesting that overall, providers are billing all five 
levels of codes. In any case, general coding rules dictate that 
providers should bill the code that most appropriately describes the 
service provided. Therefore, for CY 2007, we will finalize our proposal 
to pay clinic and emergency department visits at five levels, rather 
than three levels. We will pay for critical care services at two 
payment rates as well, as described in section IX.B.3. of this preamble 
on coding.
    We re-assessed the APC assignments for the HCPCS codes in Table 41 
using updated final rule data. Because hospitals will be reporting CPT 
codes for clinic visits for CY 2007, they must continue to distinguish 
between new and established patients and consultations according to the 
CPT code descriptor. However, it may be unnecessary for hospitals to 
report consultation CPT codes if either the new or established patient 
visit code accurately describes the service provided. We do not want to 
create an incentive for hospitals to bill a consultation code instead 
of a new or established patient code because we do not believe that 
consultation codes necessarily reflect different resource utilization 
than either new or established patient codes. Therefore, because 
consultation codes may be reported by hospitals during CY 2007, we re-
reviewed the resource costs for the consultation codes, as well as the 
clinical homogeneity of the APCs to which we proposed to map them. As a 
result of this review, we have moved the consultation codes to the same 
APC as the established patient code, for each level of service. For 
example, CPT code 99242, the level 2 consultation code is mapped to APC 
0605 (Level 2 Clinic Visits), which is where CPT code 99212, the level 
2 established patient code, is mapped. In addition, we mapped the data 
for the deleted confirmatory consultation CPT codes, 99271-99275, to 
the same APC as the corresponding consultation code. Moving the 
consultation codes to the same APC as the corresponding established 
patient visit code eliminates the incentive for hospitals to bill a 
consultation code instead of a new or established patient code. Table 
42 shows the assignment of claims data from the CY 2005 CPT E/M codes 
and other codes in the Visit APCs to the new Visit APCs for CY 2007.
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[[Page 68139]]

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[[Page 68140]]


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BILLING CODE 4120-01-C
    We have reviewed all of the public comments carefully and continue 
to believe that it is appropriate to pay Type B emergency department 
visits at clinic visit rates, until we collect enough data to better 
determine their resource costs. We have no hospital resource data that 
would support how to establish appropriate payment rates for Type B 
emergency department visits at rates between clinic and Type A 
emergency department rates. The fact that they do not operate with all 
capabilities full-time suggests that hospital resources associated with 
visits to DEDs may not be as great as those for full-time hospital 
emergency departments. Paying clinic rates for visits to Type B 
emergency departments would be consistent with current OPPS policy and 
CPT guidelines that a facility that does not meet the CPT definition of 
emergency department cannot bill emergency department CPT codes and, 
therefore, cannot receive emergency department visit payments. We agree 
with the commenter that was concerned about creating incentives for 
emergency departments to be open less than 24 hours a day, which could 
thereby place additional burden on the emergency health care system. We 
do not have precise data on how many Type B emergency departments 
currently exist, but we believe that they are currently billing the 
clinic visit CPT codes, as required under the OPPS, and thus this 
policy would have little impact on current billing practices and 
payments. Therefore, for CY 2007, we are finalizing our proposal to pay 
Type B emergency departments at clinic visit rates.
    We appreciate the efforts of the commenters that responded to our 
concern about access to rural emergency departments. As most rural 
emergency departments are open 24 hours a day, we believe Medicare 
beneficiaries in rural areas should continue to have access to 
emergency care.
    In response to the commenter that suggested that the copayment for 
emergency department visits be set at a higher rate than the copayment 
for clinic visits, we note that the statute and regulation set a 
general formula that we use to calculate copayments. As stated in 42 
CFR 419.41, for CY 2007, a copayment cannot be lower than 20 percent of 
the payment rate or greater than 40 percent of the payment rate. In 
addition, we have established through rulemaking a detailed formula 
that we use to calculate copayments. We do not artificially adjust 
copayments for any APC unless a statutory provision states that the 
standard formula does not apply. Because there is no statutory 
provision that excludes these visit APCs from the standard formula, we 
cannot ensure a specific relationship between the clinic and emergency 
department visit copayments.
    For CY 2007, we are finalizing without modification our proposal to 
create five payment levels for clinic and emergency department visits. 
We are finalizing with modification our proposal to create one payment 
level for critical care, by providing an additional payment when 
critical care is associated with trauma activation and response.

D. CY 2007 Treatment of Guidelines

1. Background
    As described in section IX.A. of the preamble of this final rule 
with comment period, since April 7, 2000, we have instructed hospitals 
to report facility resources for clinic and emergency department 
outpatient hospital visits using the CPT E/M codes and to develop 
internal hospital guidelines for reporting the appropriate visit level. 
In the CY 2003 OPPS final rule with comment period (67 FR 66792), we 
noted that an independent panel of experts would be an

[[Page 68141]]

appropriate forum to develop codes and guidelines. In that final rule 
with comment period, we also articulated a set of principles that any 
national guidelines for facility visit coding should satisfy, including 
that coding guidelines should be based on facility resources, should be 
clear to facilitate accurate payments and be usable for compliance 
purposes and audits, should meet the HIPAA requirements, should only 
require documentation that is clinically necessary for patient care, 
and should not facilitate upcoding or gaming. We stated that the 
distribution of codes should result in a normal curve.
    Subsequently, as described above, the AHA and AHIMA formed an 
independent expert panel, the Hospital Evaluation and Management Coding 
Panel, and submitted the AHA/AHIMA guidelines for reporting three 
levels of hospital clinic and emergency department visits and a single 
level of critical care services to CMS. The guidelines are based on an 
intervention model, where the levels are determined by the numbers and 
types of interventions performed by nursing or ancillary hospital 
staff. We undertook a critical review of the recommendations and made 
some modifications to the guidelines based on comments we received from 
outside hospitals and associations, clinical review, and changing 
payment policies in the OPPS regarding some separately payable 
services. In addition, as previously stated, we contracted a study to 
retrospectively code, under the modified AHA/AHIMA guidelines, hospital 
visits by reviewing hospital visit medical chart documentation gathered 
through CERT work. In summary, while the testing of the modified AHA/
AHIMA guidelines was helpful in illuminating areas of the guidelines 
that would benefit from refinement, we were unable to draw conclusions 
about the relationship between the distribution of current hospital 
reporting of visits using CPT E/M codes that are assigned according to 
each hospital's internal guidelines and the distribution of code levels 
under the AHA/AHIMA guidelines, nor were we able to demonstrate a 
normal distribution of visit levels under the modified AHA/AHIMA 
guidelines.
    Despite the inconclusive findings from the validation study, after 
reviewing the AHA/AHIMA guidelines, as well as approximately a dozen 
other guidelines for outpatient visits submitted by various hospitals 
and hospital associations, we believe that the AHA/AHIMA guidelines are 
the most appropriate and well-developed guidelines for use in the OPPS 
of which we are aware. Our particular interest in these guidelines is 
based upon the broad-based input into their development, the need for 
CMS to move definitively to promulgate national outpatient hospital 
visit coding guidelines in the near future, and full consideration of 
the characteristics of alternative types of guidelines. We also believe 
that hospitals will react favorably to guidelines developed and 
supported by the AHA and AHIMA, national organizations that have great 
interest in hospital coding and payment issues, and possess significant 
medical, technical and practical expertise due to their broad 
membership, which includes hospitals and health information management 
professionals. Anecdotally, we have been told that a number of 
hospitals are successfully utilizing the AHA/AHIMA guidelines to report 
levels of hospital visits. However, other organizations have expressed 
concern that the AHA/AHIMA guidelines may result in a significant 
redistribution of hospital visits to higher levels, reducing the 
ability of the OPPS to discriminate among the hospital resources 
required for various different levels of visits. We, too, remain 
concerned about the potential redistributive effect on OPPS payments 
for other services or among levels of hospital visits when national 
guidelines for outpatient visit coding are adopted. We recognize that 
there may be difficulty crosswalking historical hospital claims data 
from current CPT E/M codes reported based on individual internal 
hospital guidelines to payments for any new coding system developed, in 
order to provide appropriate payment levels for hospital visits 
reported based on national guidelines in the future.
    There are several types of problems with the AHA/AHIMA guidelines 
that have been identified based upon extensive staff review and 
contractor use of the guidelines during the validation study. We 
believe the AHA/AHIMA guidelines require short-term refinement prior to 
their full adoption by the OPPS, as well as continued refinement over 
time after their implementation. Our modified version of the AHA/AHIMA 
guidelines provides some possibilities for addressing certain issues. 
Our eight general areas of concern regarding the AHA/AHIMA model are 
listed below. In addition, we have posted to the CMS Web site both the 
original AHA/AHIMA guidelines and our modified draft version. In the CY 
2007 OPPS proposed rule (71 FR 49616), we sought public input before we 
adopt national guidelines.
    We continue to commit that we will provide a minimum of 6-12 months 
notice to hospitals prior to implementation of national guidelines to 
provide sufficient time for providers to make the necessary systems 
changes and educate their staff.
2. Outstanding Concerns with the AHA/AHIMA Guidelines
a. Three Versus Five Levels of Codes
    The AHA/AHIMA guidelines describe three levels of codes for clinic 
and emergency department visits, rather than the five levels of codes 
that currently exist for clinic and emergency department visits. We 
believe that it is difficult to pay at five levels using these 
guidelines, unless the guidelines were revised, because hospitals would 
not have guidelines that applied to the Level 2 and Level 4 visits. As 
discussed above, our claims data indicate that five payment levels are 
justified for both clinic and Type A emergency department visits, and, 
therefore, we are finalizing five levels of clinic and emergency 
department visit payments so that providers may code at five visit 
levels and receive payments at five levels as well. In fact, the 
materials explaining the AHA/AHIMA guidelines state that one of the 
reasons that the model includes only three coding levels is because CMS 
only paid at three payment levels. We will now pay at five payment 
levels for CY 2007 and believe the AHA/AHIMA guidelines may need to be 
revised to reflect five visit levels.
b. Lack of Clarity for Some Interventions
    Some interventions are vague, unclear, or nonspecific, without 
sufficient examples of documentation in the medical record that may 
support those interventions. For instance, it is unclear what 
documentation for the intervention stated as ``Patient registration, 
room setup, patient use of room, room cleaning'' and assigned in the 
AHA/AHIMA guidelines to a low-level clinic visit would be necessary to 
support all aspects of that intervention. In another case, the 
intervention ``Frequent monitoring/assessment as evidenced by two sets 
of vital sign measurements or assessments'' that is attributable to a 
mid-level emergency department visit in the guidelines explains that 
this may include assessment of cardiovascular, pulmonary, or 
neurological status. However, it is unclear exactly what coders should 
look for in the medical record to support this intervention and whether 
narrative hospital staff descriptions of patient status would be 
considered to be assessments. These

[[Page 68142]]

examples, and others, were identified by the contractor engaged in 
medical chart reviews as part of the guidelines validation study. The 
AHA/AHIMA guidelines may benefit from revisions to clarify some 
interventions and/or provide additional examples based upon questions 
that arose during field testing of the guidelines or that are raised by 
hospitals reviewing the AHA/AHIMA guidelines and the modified version 
posted on our Web site.
c. Treatment of Separately Payable Services
    CMS and the APC Panel stated that separately payable services 
should be excluded from the guidelines because of their concern over 
the potential for double payment for hospital resources attributed to 
visit services when those resources were actually used to provide the 
separately payable services. Consistent with this policy, at the time 
of their development, the AHA/AHIMA guidelines excluded all services 
separately payable under the OPPS from the list of interventions. For 
policy consistency, in our modified draft version of the guidelines, we 
removed interventions that have now become separately payable under the 
OPPS through CY 2006, such as bladder catheterizations and some wound 
care services. However, upon further reflection as we move forward to 
implement national guidelines, in the proposed rule, we indicated that 
we are open to reconsidering whether the inclusion of some separately 
payable services in guidelines to determine visit levels could serve as 
a proxy for the resources that the patient will consume and that should 
be attributable to the hospital visit, not the separately payable 
services. In such cases, consideration of separately payable services 
in reporting visit levels may not result in double payment for 
components of those separately payable services. There may be hospital 
resources used in visits that are not captured in the AHA/AHIMA 
guidelines' limited number of interventions that are not separately 
payable. We believe that, in general, a patient with high medical 
acuity will consume more hospital resources in the visit than a patient 
with moderate acuity. However, when separately payable interventions 
are removed from the model, it may be difficult for the limited 
interventions remaining in the guidelines for each visit level to 
capture the acuity level of the patient. In addition, the list of HCPCS 
codes that are packaged can change annually. For example, in the CY 
2006 OPPS, bladder catheterization services, which had been packaged in 
prior years, were first made separately payable, provided certain 
conditions were met. If the guidelines strictly excluded all separately 
payable services, the guidelines could also change from year to year, 
possibly requiring additional education of hospital staff on an annual 
basis. An extremely ill emergency department patient who may need a 
significant number of separately payable procedures, but only one or 
two minor interventions that are not separately payable, may require 
significant time and attention from hospital staff that is unrelated to 
the hospital resources generally required for the separately payable 
procedures. The guidelines may indicate that a low level emergency 
department visit code should be billed, while, in fact, the patient may 
require significantly more hospital resources than a mildly ill patient 
who received the same two minor interventions. In the proposed rule, we 
indicated that we are open to further discussion and welcomed public 
comments on the exclusion of separately payable services from the 
national visit guidelines and whether their inclusion could pose a risk 
of attributing the same hospital resources to both visits and 
separately payable services, potentially resulting in duplicate 
payments for those resources.
d. Some Interventions Appear Overvalued
    Several interventions that we believe may be minor are valued at a 
high level in the guidelines. This could result in visits with 
relatively less resource intensive interventions being coded as high 
level visits, leading to an overall visit distribution that was skewed 
toward the high end. Claims data then would fail to reflect the 
differential hospital resources associated with hospital visits of five 
levels. For example, the AHA/AHIMA guidelines consider oxygen 
administration, described as initiation and/or adjustment from a 
baseline oxygen regimen, to be a mid-level emergency department 
intervention, while we believe that the associated hospital resources 
could be more consistent with its characterization as a low-level 
emergency department intervention. In another example, the AHA/AHIMA 
guidelines consider specimen collection(s), other than venipuncture and 
other separately payable services, to be a mid-level clinic 
intervention, while we believe this may be more consistent with other 
low-level clinic interventions, depending upon the numbers and types of 
different specimens collected. In the proposed rule, we encouraged 
specific comments on the levels assigned to various interventions in 
the guidelines, with the goal of differentiating five levels of 
services in a normal distribution, based on their respective hospital 
resources.
e. Concerns of Specialty Clinics
    The AHA/AHIMA guidelines are unlikely to sufficiently address the 
concerns of various specialty clinics (for example, pain management 
clinics, oncology clinics, and wound care centers). Anecdotally, we 
have heard that the interventions listed in the AHA/AHIMA guidelines do 
not include many of the interventions commonly performed in specialty 
clinics and that some of the interventions in the guidelines would 
never be performed in certain types of clinics. Currently, each 
provider has its own set of guidelines, and we believe that some 
specialty clinics have customized guidelines to facilitate coding their 
visits at different levels based upon the specific hospital resources 
commonly used in visits to their clinics. While we prefer to have one 
model that can be applied nationally to each level of clinic visit code 
for which we make a specific OPPS payment, we are unsure as to whether 
one model can adequately characterize visit levels for all types of 
clinics. For example, we have been told that the most appropriate proxy 
for facility resource consumption in cancer care is staff time due to 
the intensive staff interactions required to care for patients with 
cancer, regardless of the reasons for their clinic visits. In the 
proposed rule, we expressed interest in receiving comments regarding 
the feasibility of applying national guidelines to specialty clinic 
visits while ensuring appropriate OPPS payments for those services and 
suggestions for revisions to the guideline models posted that could 
improve their utility in reporting such visits.
f. Americans With Disabilities Act
    We are concerned that the AHA/AHIMA guidelines' intervention 
related to the special needs of certain patients may be in violation of 
the Americans with Disabilities Act, as it may increase the visit level 
reported, thereby increasing a patient's copayment. Even if additional 
hospital resources are required to treat patients with disabilities, 
patients must not have additional financial liability for those 
services based on their disabilities.
g. Differentiation Between New and Established Patients and Between 
Standard Visits and Consultations
    The AHA/AHIMA guidelines do not differentiate between new versus

[[Page 68143]]

established patients or consultations versus standard visits for clinic 
visits. During the summer 2002 APC Panel meeting, the APC Panel 
recommended that CMS not differentiate among visit types, specifically 
new, established, and consultation visits, for the purposes of clinic 
visit facility coding. Therefore, in the August 9, 2002 OPPS proposed 
rule, we proposed to accept the APC Panel's recommendation to create 
five new G-codes to replace the CPT new and established clinic visit 
and consultation E/M codes. We did not finalize the codes for CY 2003 
because of concerns then about creating new G-codes without national 
guidelines.
    During CY 2006 and earlier, there has not been a payment difference 
between new and established patient visits of the same level, as 
generally both were mapped to the same APC. The information describing 
the AHA/AHIMA guidelines indicates that only one set of guidelines was 
developed for five levels of codes for clinic visits, regardless of a 
patient's status as a new or established patient or the provision of a 
consultation visit. This approach may have been related to the lack of 
a payment differential for different types of clinic visits of the same 
level under the OPPS when those guidelines were developed. However, 
several years of hospital claims data regarding the median costs of the 
specific CPT clinic visit E/M codes consistently indicate that new 
patients generally are more resource intensive than existing patients 
across all visit levels, and that consultations are more resource 
intensive than standard visits, but similar in terms of resources to 
new patient visits. For example, based upon the final CY 2005 claims 
used by the OPPS for CY 2007 ratesetting, CPT code 99213, the level 3 
clinic visit code for established patients, has a median cost of 
$60.70. CPT code 99203, the level 3 clinic visit code for new patients, 
has a median cost of $72.33. CPT code 99243, the level 3 consultation 
visit code, has a median cost of $72.89. Finally, CPT code 99273, the 
level 3 confirmatory consultation visit code that was deleted for CY 
2006 had a median cost of $98.24. In the proposed rule, we encouraged 
public comments that discuss the potential differences in hospital 
clinic resource consumption for new patient visits, established patient 
visits, and consultations. If there are significant additional hospital 
resources required to provide new patient visits or consultations, we 
are unsure whether the interventions in the AHA/AHIMA guidelines would 
reliably capture these additional resources.
h. Distinction Between Type A and Type B Emergency Departments
    There are no AHA/AHIMA guidelines for the reporting of visits to 
Type B emergency departments that meet the EMTALA definition of a DED, 
but do not meet the proposed definition of a Type A emergency 
department, as discussed above. When the AHA and AHIMA created these 
guidelines, emergency departments that did not meet the CPT definition 
of emergency department were instructed to bill CPT clinic visit E/M 
codes. There was no distinction in CPT reporting between emergency 
departments that, as DEDs, had an EMTALA obligation but did not meet 
the CPT definition of emergency department and outpatient hospital 
clinics that did not provide emergency services. For the new G-codes 
that we created in this final rule with comment period for CY 2007 for 
Type B emergency departments to use in reporting visits, in the short 
run hospitals will use internal guidelines to determine their visit 
levels for Type B emergency department visits, as they will for visits 
to both clinics and Type A emergency departments. However, with the 
implementation of national hospital visit guidelines, we will need to 
specify those guidelines to be used for the purposes of Type B 
emergency department visit reporting. The AHA and AHIMA have not yet 
had the opportunity to consider the issue of Type B emergency 
department visit reporting in their guidelines, and in the proposed 
rule we welcomed public comments to provide additional perspectives on 
the appropriate guidelines for reporting visit levels in these Type B 
emergency departments.
    We received a large number of comments related to national 
guidelines for clinic and emergency department visits and critical care 
services, some of which described general questions and concerns about 
using a national model and others with specific suggestions for 
improving the AHA/AHIMA model. As noted in the CY 2007 proposed rule, 
we sought broad public input regarding our discussion of national 
guidelines to inform our guidelines development efforts at this point 
in time, but we made no specific proposal for CY 2007. Therefore, the 
comments below are summarized to reflect the breadth and depth of 
thoughtful input provided by the public, and we will continue to 
consider these comments and additional public input as we work to 
develop national guidelines for future implementation.
    Comment: Most commenters strongly supported creation of national 
guidelines, but a few commenters preferred to continue using the 
internal guidelines that they had been using for several years. Some 
hospitals had successfully implemented the original AHA/AHIMA model, 
while others had success with diagnosis-related models and resource 
intensity point scoring models. One commenter indicated that a 
diagnosis-based model is not as complicated as we described. The 
commenter's hospital had great success training its staff and now has 
little coding variability among its coders. One developer of national 
guidelines noted that many hospitals had success with problem-based 
guidelines that it had created. The developer noted that its system was 
easy to use, produced consistent coding decisions with a normal 
distribution of visits, and even served as a tool to track 
effectiveness and efficiency. One hospital asked if it was permitted to 
continue using its own internal guidelines if CMS had indicated some 
concerns with that particular type of guidelines. Several hospitals 
asked us to clarify whether a normal distribution would be expected 
nationally, across all hospitals, or for an individual hospital. The 
commenter suggested that it would be appropriate for a trauma center to 
have a curve that was skewed to the right, toward higher level visit 
codes. Another commenter suggested that hospitals be instructed to bill 
the same level code that is billed on the physician side, to simplify 
coding and reduce excess documentation. The commenter noted that then 
there would be no concern about redistributive impact because we could 
simply study the physician E/M code distribution. One commenter 
requested that the final guidelines use criteria and/or interventions 
that would be available in electronic medical records, to ease 
guideline implementation for hospitals with this technology. The same 
commenter suggested that the guidelines should be very specific and 
serve as detailed coding instructions rather than just ``guidelines,'' 
which would make training easier and reduce the number of questions 
directed at the fiscal intermediaries. The commenter suggested that the 
guidelines include details, with regulation citations such as ``the 
patient must be a registered outpatient of the hospital'' as defined in 
a particular regulation. Several commenters requested that we clarify 
that the clinic guidelines are intended to be used by any outpatient 
area that is not an emergency department, even if that outpatient area 
is not a true clinic and suggested that the guidelines should be titled 
``Outpatient visit

[[Page 68144]]

guidelines'' instead of ``Clinic visit guidelines.'' One commenter gave 
examples of outpatient areas that are not clinics, which included 
outpatient infusion centers, outpatient oncology centers, wound care 
centers, and outpatient maternity services.
    We received many specific comments about the AHA/AHIMA model. The 
AHA and AHIMA were pleased that we are working on their model and look 
forward to reconvening the expert panel to continue work on this 
project. They noted that the model was an initial attempt with a short 
turnaround time, and that it was never intended to be used as a stand-
alone document. They anticipated creating educational supplemental 
materials that would accompany the guidelines. Several organizations 
expressed interest in working with CMS as well as the AHA/AHIMA expert 
panel in the development of national guidelines, including the American 
College of Emergency Physicians and Lynx Medical Systems.
    Several commenters agreed that it was appropriate to continue with 
five levels of coding to achieve consistency with other payors. Other 
commenters agreed that retaining five coding levels was appropriate if 
five payment rates existed. One commenter believed that three levels 
was simpler and distinguished hospital coding from physician coding, 
which has five coding levels. The AHA and AHIMA noted that the 
guidelines originally used three levels because the expert panel found 
it hard to distinguish between five levels when separately payable 
services were excluded. However, if separately payable services or 
other factors such as time could be included, the model could be 
modified to account for five levels. They requested clear guidance from 
CMS before proceeding.
    Many commenters agreed that multiple interventions were unclear and 
could be interpreted in several ways. Other commenters asked CMS to 
clarify exactly which interventions were unclear. One commenter noted 
that over time, after the guidelines are implemented, the ambiguities 
will decrease as staff becomes familiar with the model. Several 
commenters suggested that specific examples of patient acuity or 
symptoms would be useful. (We noted above that the AHA and AHIMA 
anticipated that they would provide significant supplemental 
materials.) Several commenters asked that we clarify the difference 
between ``triage'' and the medical screening exam required under EMTALA 
provisions. One commenter suggested that CMS only use interventions 
that measure quantitative items such as blood pressure, heart rate, and 
pain threshold scoring, and like items.
    Most commenters believed that separately payable interventions 
should be included in the guidelines because they serve as a proxy for 
resource use. One commenter noted that the American College of 
Emergency Physicians' guidelines have an excellent list of 
interventions, some of which are separately payable. One commenter 
suggested that we assign a modifier to a code that is separately paid 
so that it would not be counted toward calculating a visit level. The 
AHA and AHIMA aptly noted that not all separately payable services 
reflect patient acuity, so it would be necessary for the Panel to 
determine which services are appropriate for inclusion. One commenter 
asked that we continue to exclude separately payable services to avoid 
double billing and confusion.
    Some commenters indicated that most interventions in the original 
AHA/AHIMA model were appropriately placed, with some interventions that 
were valued too low and a few that were valued too high. Other 
commenters disagreed with several CMS-suggested revisions. For example, 
in the revised model, if emergency department staff performed a body 
assessment, pain measurement, vitals, and an x-ray, that service would 
no longer reach a level 1 visit, while under the original AHA/AHIMA 
guidelines, the service would be coded as a Level 1 visit. Several 
commenters argued that oxygen administration should not be moved to a 
low level because it is resource-intensive in terms of staff time and 
resource use. One commenter stated that specimen collection was 
appropriately assigned as a Level 1 intervention in a clinic setting 
but should be higher in the emergency department because staff often 
need to assist patients who are anxious and having trouble 
concentrating. Another commenter suggested Level 1 assignment for one 
to two specimen collections and Level 3 for three or more collections. 
Two hospitals speculated that their emergency department payment would 
decrease by 30 to 40 percent as a result of transitioning to the AHA/
AHIMA guidelines. There were additional suggestions that specific 
interventions move from one level to another. Several commenters 
suggested additional interventions that should be included, such as 
restroom assistance, memory testing, reviewing medications, obtaining 
insurance authorization, psychological and spiritual counseling, 
emotional support, time with the family, discharge instructions, 
seizure precautions, drug/alcohol influence, prepping for surgery, 
postmortem care, dietary planning, pain management, and others. 
Although pre-authorization is not required for Medicare beneficiaries, 
some commenters noted that hospitals will use these guidelines for all 
payors, so it may be appropriate to include this intervention. One 
commenter agreed that continuous irrigation of the eye should not be a 
Level 5 visit. The AHA and AHIMA stated that its expert Panel looked 
carefully at each intervention. They noted that their criteria for 
placement included hospital staff time involved, complexity of 
intervention, number of hospital staff members required to perform the 
intervention, and the skill level, qualifications, or credentialing 
needed to perform the intervention. Other commenters noted that the 
interventions were focused on interventions performed by nurses, rather 
than by assorted clinicians and technicians. One hospital expressed 
interest in submitting further suggestions after the comment period 
ended.
    We received a few comments about applying one set of guidelines to 
all clinics, including specialty clinics, suggesting that it was 
unnecessary to create multiple guidelines. Several commenters suggested 
that any differences could be addressed with time as an element, which 
is the single biggest resource that varies among clinics. For example, 
a diabetic patient with limited eyesight requires additional training 
time to learn to read glucose levels and give the proper amount of 
insulin. A cancer association submitted an additional example, 
explaining that a simple blood draw can be time consuming when 
performed on an oncology patient, whose veins may be damaged from the 
effects of chemotherapy. One commenter suggested that if more than 50 
percent of a visit is used for counseling and care coordination, the 
visit level should be increased by one level. Several associations 
stated that it is unlikely that one set of guidelines could apply to 
all specialty clinics. Specifically, one wound care association 
recommended that all wound care clinics use the guidelines developed by 
that particular association. Another wound care association developed 
an acuity scoring system that has been successfully implemented by 
wound care clinics.
    One commenter suggested that in a time-based model, there would be 
no American with Disabilities Act (ADA) violation. Another commenter 
suggested setting a flat copayment rate for all clinic and all 
emergency department visits to avoid an ADA violation. The

[[Page 68145]]

AHA and AHIMA clarified that their intention was not to increase the 
beneficiary copayment but was intended to reflect resource utilization.
    We discuss in sections IX.B. and C. of this preamble the comments 
that we received about the distinction among ``new'' and 
``established'' visits and ``consultations.'' A few commenters 
suggested that a new patient could be a contributing factor in the 
guidelines.
    We also discuss in sections IX.B of this preamble the comments that 
we received about Type A versus Type B emergency departments. We 
received no comments on this topic that were specific to the AHA/AHIMA 
guidelines.
    One organization noted that some revisions may have been necessary 
due to changes in clinical practice since the guidelines were developed 
3 years ago. Another commenter noted that several Level 1 emergency 
department interventions, such as first aid, are Level 3 clinic 
interventions, which leads to emergency departments receiving less 
payment for the same service, even though emergency departments are 
costlier.
    The AHA and AHIMA requested that CMS release the detailed analysis 
of the Iowa Foundation for Medical Care review of the AHA/AHIMA model 
so that they can review all concerns. They also requested that CMS 
clarify the rationale for the other modifications. For example, it 
sometimes appeared to them as if CMS measured physician time rather 
than facility resources or hospital staff time. For example, patient 
education by hospital staff was removed but physician counseling of 
more than 60 minutes was added.
    Response: We appreciate all the comments we received from the 
public, and we encourage continued submission of comments at any time 
that will assist us, the AHA/AHIMA expert panel, and other stakeholders 
interested in the development of national guidelines. Until national 
guidelines are established, hospitals should continue using their own 
internal guidelines, even if we have expressed reservations about the 
type of guidelines that a hospital is currently using. As commenters 
stated, we would not expect individual hospitals to experience a normal 
distribution of visit levels, although we would expect a normal 
distribution across all hospitals after national guidelines are 
established. We would expect that a small community hospital may 
provide more low-level services than high-level services, while an 
academic medical center or trauma center may provide more high-level 
services than low-level services. The commenters are correct that we 
intend for these national guidelines to be used by any outpatient 
hospital department, even if it is not called a clinic.
    We would expect these national guidelines to provide for five 
levels of coding, to parallel the five payment levels that are 
finalized in this final rule with comment period. It would be 
impossible to code at three levels and pay at five levels. As described 
above, we believe that paying at five levels will allow a more accurate 
payment for clinic and emergency department visits.
    We agree with commenters that there may be advantages to including 
separately payable interventions in the guidelines as examples, because 
a measure of acuity may be lost in the absence of recognition of these 
procedures. We also agree with the AHA and AHIMA that it might be 
easier to distinguish among five levels of coding if separately payable 
interventions are included as examples.
    We appreciate all of the specific comments about interventions that 
may not be appropriately assigned to levels in the guidelines. We 
acknowledge that the guidelines are still being developed and require 
additional testing. While it would be impossible for every single 
hospital to agree about the placement of every single intervention in 
the guidelines, we anticipate that the interventions will be assigned 
in a way that best reflects the resource use of the services provided 
such that few providers will have objections. We remind providers that 
under a relative system, if a service is listed as a Level 1 
intervention, it does not mean that very few hospital resources are 
involved. Instead, it means that the resources used in that service 
must be considered relative to the other interventions in the model.
    While most commenters believed that one set of guidelines could 
apply to all specialty clinics, it may be necessary to incorporate time 
into the guidelines as well. The AHA and AHIMA expert panel has 
considered this issue as well.
    We will determine whether the Iowa Foundation for Medical Care 
study of the modified AHA/AHIMA model can be released to the public.
    The public comments that we received on this guidelines section of 
the proposed rule are publicly available to the AHA and AHIMA and their 
expert panel, as well as other interested parties, along with comments 
that we received on the two versions of the guidelines posted on the 
CMS Web site at: http://www.cms.hhs.gov. We hope to receive additional 
input from the AHA and AHIMA and other stakeholders over the upcoming 
months to address the eight areas of concern that are discussed above, 
as well as the other issues reviewed above that have been brought to 
our attention by the public. We plan to communicate progress on the 
development of OPPS visit guidelines through updates to the OPPS Web 
site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/ and we may post 
other versions of draft guidelines in order to solicit additional 
public input during CY 2007. When we post additional materials to the 
Web site for purposes of providing information or soliciting further 
comments regarding national guidelines, we will update the public 
through all means practically available to us, including communications 
with professional associations, list-serves, and other broad-based 
communication forums.
    While we understand the interest of some hospitals in our moving 
quickly to promulgate national guidelines that will ensure standardized 
reporting of outpatient hospital visit levels, we believe that the 
issues we have identified and others that may arise are important and 
require serious consideration prior to the implementation of national 
guidelines. Because of our commitment to provide hospitals with 6-12 
months notice prior to implementation of national guidelines, we expect 
that we would not implement national guidelines prior to CY 2008. We 
acknowledge that, once implemented, the guidelines will require 
periodic review and updating based on factors such as changing medical 
practices, hospital experiences in reporting the codes, new payment 
policies under the OPPS, and median costs for levels of services 
calculated from claims data. We are hopeful that the information 
received from the AHA, AHIMA and others on such reviews would permit us 
to effectively, and in a timely manner, address emerging guideline 
implementation issues, as well as develop desirable future 
modifications to the guidelines based on hospitals' experiences 
reporting commonly provided visits. We believe that this ongoing and 
evolving system should provide the most successful approach to ensuring 
that OPPS national visit guidelines continue to facilitate consistent 
and standardized reporting of outpatient hospital visits, in a manner 
that is resource-based and supportive of appropriate OPPS payments for 
the efficient and effective provision of visits in hospital outpatient 
settings.

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X. Payment for Blood and Blood Products

A. Background

    Since the implementation of the OPPS in August 2000, separate 
payments have been made for blood and blood products through APCs 
rather than packaging them into payments for the procedures with which 
they were administered. Hospital payments for the costs of blood and 
blood products, as well as the costs of collecting, processing, and 
storing blood and blood products, are made through the OPPS payments 
for specific blood product APCs. On April 12, 2001, CMS issued the 
original billing guidance for blood products to hospitals (Program 
Transmittal A-01-50). In response to requests for clarification of 
these instructions, CMS issued Program Transmittal 496 on March 4, 
2005. The comprehensive billing guidelines in the Program Transmittal 
also addressed specific concerns and issues related to billing for 
blood-related services, which the public had brought to our attention.
    In the CY 2000 OPPS, payments for blood and blood products were 
established based on external data provided by commenters due to 
limited Medicare claims data. From the CY 2000 OPPS to the CY 2002 
OPPS, payment rates for blood and blood products were updated for 
inflation. For the CY 2003 OPPS, as described in the November 1, 2002 
final rule with comment period (67 FR 66773), we applied a special 
adjustment methodology to blood and blood products that had significant 
reductions in payment rates from the CY 2002 OPPS to the CY 2003 OPPS, 
when median costs were first calculated from hospital claims. Using the 
adjustment methodology, we limited the decrease in payment rates for 
blood and blood products to approximately 15 percent. For the CY 2004 
OPPS, as recommended by the APC Panel, we froze payment rates for blood 
and blood products at CY 2003 levels as we studied concerns raised by 
commenters and presenters at the August 2003 and February 2004 APC 
Panel meetings.
    For the CY 2005 OPPS, we established new APCs that allowed each 
blood product to be assigned to its own separate APC, as several of the 
previous blood product APCs contained multiple blood products with no 
clinical homogeneity or whose product-specific median costs may not 
have been similar. Some of the blood product HCPCS codes were 
reassigned to the new APCs (Table 34 of the November 15, 2004 final 
rule with comment period (69 FR 65819)).
    We also noted in the November 15, 2004 final rule with comment 
period, that public comments on previous OPPS rules had stated that the 
CCRs that were used to adjust charges to costs for blood products in 
past years were too low. Past commenters indicated that this approach 
resulted in an underestimation of the true hospital costs for blood and 
blood products. In response to these comments and APC Panel 
recommendations from its February 2004 and September 2004 meetings, we 
conducted a thorough analysis of the CY 2003 claims (used to calculate 
the CY 2005 APC payment rates) to compare CCRs between those hospitals 
reporting a blood-specific cost center and those hospitals defaulting 
to the overall hospital CCR in the conversion of their blood product 
charges to costs. As a result of this analysis, we observed a 
significant difference in CCRs utilized for conversion of blood product 
charges to costs for those hospitals with and without blood-specific 
cost centers. The median hospital blood-specific CCR was almost two 
times the median overall hospital CCR. As discussed in the November 15, 
2004 final rule with comment period, we applied a methodology for 
hospitals not reporting a blood-specific cost center, which simulated a 
blood-specific CCR for each hospital that we then used to convert 
charges to costs for blood products. Thus, we developed simulated 
medians for all blood and blood products based on CY 2003 hospital 
claims data (69 FR 65816).
    For the CY 2005 OPPS, we also identified a subset of blood products 
that had less than 1,000 units billed in CY 2003. For these low-volume 
blood products, we based the CY 2005 OPPS payment rate on a 50/50 blend 
of the CY 2004 OPPS product-specific OPPS median costs and the CY 2005 
OPPS simulated medians based on the application of blood-specific CCRs 
to all claims. We were concerned that, given the low frequency in which 
these products were billed, a few occurrences of coding or billing 
errors may have led to significant variability in the median 
calculation. The claims data may not have captured the complete costs 
of these products to hospitals as fully as possible. This low-volume 
adjustment methodology also allowed us to further study the issues 
raised by commenters and by presenters at the September 2004 APC Panel 
meeting, without putting beneficiary access to these low-volume blood 
products at risk.
    Overall, median costs from CY 2003 (used for the CY 2005 OPPS) to 
CY 2004 (used for the CY 2006 OPPS) were relatively stable, with a few 
significant increases and decreases from the CY 2005 adjusted median 
costs for some specific blood products. For the CY 2006 OPPS, we 
adopted a payment adjustment policy that limited significant decreases 
in APC payment rates for blood and blood products from the CY 2005 OPPS 
to the CY 2006 OPPS to not more than 5 percent. We applied this 
adjustment to 11 blood and blood product APCs for the CY 2006 OPPS, 
which we identified in Table 33 of the CY 2006 OPPS final rule with 
comment period. For the CY 2006 OPPS, we set the final median costs for 
blood and blood products at the greater of: (1) The simulated median 
costs calculated from the CY 2004 claims data; or (2) 95 percent of the 
CY 2005 OPPS adjusted median costs for these products, as reflected in 
Table 33 published in the CY 2006 OPPS final rule with comment period.

B. Policy Changes for CY 2007

    In the CY 2007 OPPS proposed rule, we proposed to base CY 2007 
payment rates for blood and blood products on their median costs from 
CY 2005 claims data, calculated using a special methodology to simulate 
blood-specific CCRs if hospitals did not have such specific CCRs. After 
hearing several public presentations at the August 2006 APC Panel 
meeting, the Panel engaged in considerable deliberation and recommended 
that CMS reconsider its methodology to develop payment rates for blood 
and blood products to more accurately reflect the true costs of blood 
and blood products to hospitals, including using external data. We 
include our response to this recommendation in the discussion below.
    We received a number of public comments regarding this proposal. A 
summary of the comments and our responses follows:
    Comment: A number of commenters objected to our proposal to base 
payments for blood and blood products on their simulated median unit 
costs. They stated that the proposed payments are inadequate to 
compensate hospitals for the full acquisition costs of blood and blood 
products. Some commenters said that they appreciated CMS' work to 
calculate more appropriate payment rates for blood and blood products, 
but urged CMS to use external data, rather than claims-based data, as a 
measure of the appropriateness of the median costs derived from the 
claims process. Specifically, the commenters asked CMS to set the 
payments for four blood products at 110 percent of the average hospital 
purchase price for four blood products, specifically, P9016, RBC 
Leukocytes reduced; P9017, Plasma 1

[[Page 68147]]

donor frz w/in 8 hr; P9019, and Platelets; P9035, Platelet pheresis 
leukoreduced as determined from data submitted by 1600 hospitals in 
response to a survey of 2004 blood costs that was conducted by the 
Department of Health and Human Services under a contract with the 
American Association of Blood Banks (AABB). The commenters believed 
that the 10 percent increase over the survey purchase price findings 
was necessary to update the amounts to reflect what they thought would 
be the costs to hospitals for these blood products in CY 2007. They 
stated that the amounts that resulted were very conservative because 
they reflected only the cost of the blood and its processing, without 
including a hospital allowance for the costs of overhead, storage, 
handling, and waste due to shelf-life limitations. Other commenters 
asked CMS to set the blood median costs for CY 2007 at 12 percent 
higher than the proposed rule median costs, because such an increase 
would result in a significant improvement in reimbursement for products 
for which the OPPS claims data understated true acquisition costs and 
would help to ensure continued beneficiary access to the nation's blood 
supply. Some commenters asked that CMS set the payment for blood at the 
charge established by large suppliers of blood products. Several 
commenters requested that CMS calculate the median costs for blood and 
blood products using only claims with dates of service after July 1, 
2005, so that the only claims used in median calculation for these 
products would be claims that were submitted after the billing guidance 
and coding edits of CMS Program Transmittal 496 went into effect on 
July 1, 2005. Other commenters suggested that we establish median costs 
for basic blood products and, separately, for different types of 
additional blood processing (for example, irradiation and 
leukoreduction) to ensure that there would be no rank order anomalies 
in the medians derived from claims data.
    Response: In developing this CY 2007 final rule with comment 
period, we are accepting the APC Panel's recommendation to review our 
methodology for developing payment rates for blood and blood products. 
We have also considered the only recent external data of which we are 
aware that was mentioned by several commenters. The recent survey by 
the AABB included reporting of the hospital purchase prices related to 
providing 4 of the 34 blood and blood products for which we have 
specific HCPCS codes. An abstract of the resulting report, including 
the average amounts hospitals paid for the four blood products in CY 
2004, is available in the journal ``Transfusion,'' 2006 volume 46 
Supplement (page 188A). We reviewed the limited information that is 
currently available from the survey for these four blood products. 
However, we are unable to determine the extent to which the survey 
findings could be useful in evaluating the methodology and resulting 
median costs that were the basis for our CY 2007 proposal of payment 
rates for all blood and blood products. Our payment methodology for 
blood and blood products has historically been based upon median 
hospital costs (consistent with the standard OPPS claims-based 
methodology for establishing payment rates), and the survey reported 
average hospital purchase prices, rather than median costs. Moreover, 
this information was not available to the public at the beginning of 
the comment period of the CY 2007 OPPS proposed rule, and hence we were 
not able to request and consider public comments on it. The OPPS 
methodology to establish relative weights requires standardized cost 
finding applied to a standardized source of data to ensure that the 
relative weights for the items and services paid under the system are 
in the correct relationship to one another. To select four blood 
products for treatment outside of the standard methodology, 
substituting external data for claims data, may not result in weights 
that are appropriately relative to one another. Accordingly, we are not 
using the AABB survey data in determining the payment rates for blood 
and blood products for the CY 2007 OPPS.
    We also are not adopting one suggestion of the commenters to 
establish rates based upon the amounts charged by the largest suppliers 
of blood, because as described earlier regarding use of the AABB survey 
data, to do so would be contrary to the methodology of the OPPS that is 
based on a system of relative weights. Similarly, we do not believe it 
would be appropriate to increase the final median costs of blood and 
blood products by 12 percent over their proposed CY 2007 median costs 
because little justification was provided by the commenters for the 
increase. Lastly, we do not believe we should calculate median costs 
for this final rule using only claims submitted on or after the July 1, 
2005, effective date of the blood instructions in Transmittal 496, 
because to do so would greatly reduce the number of claims for the low 
volume blood products. The rates for these products tend to volatile 
even with an entire year of claims data, because they are furnished in 
very low volume in outpatient hospital settings. We also are not 
setting median costs for the product without processing and 
establishing separate median costs for each different type of 
processing. Hospitals generally acquire the product processed as 
specified in the definition of the product they report, and we do not 
believe that they would be able to charge separately for the 
unprocessed product (for example, red blood cells) and also charge 
separately for the processing that occurred before they acquired the 
already processed product.
    Instead, for the CY 2007 OPPS, we are finalizing our proposal to 
establish payment rates for blood and blood products by using the same 
simulation methodology described in the November 15, 2004 final rule 
with comment period (69 FR 65816), which utilizes hospital-specific 
actual or simulated CCRs for blood cost centers to convert hospital 
charges for blood and blood products to costs. We continue to believe 
that using blood-specific CCRs applied to hospital claims data will 
result in payments that more fully reflect hospitals' true costs of 
providing blood and blood products than our general methodology of 
defaulting to the overall hospital CCR when more specific CCRs are 
unavailable. However, for CY 2007 we are providing a payment transition 
for those blood products for which the difference between their CY 2006 
adjusted median cost and their CY 2007 simulated median cost is greater 
than 25 percent. Specifically, we are setting the CY 2007 median costs 
upon which payments for blood and blood products are based at the 
higher of the CY 2007 unadjusted simulated median cost or 75 percent of 
the CY 2006 adjusted median cost on which the CY 2006 payment is based. 
This results in adjustment to the simulated median costs for CY 2007 
for 7 of the 34 blood products. See Table 43 below.
    The median costs for blood and blood products in this final rule 
with comment period are derived from the CY 2005 claims data and have 
the benefit of reflecting, in part, the clarifications about reporting 
that were provided through CMS Program Transmittal 496, dated March 4, 
2005. This instruction articulated and clarified many questions that 
had been raised by hospitals and others about how hospitals should 
report charges for blood and blood products. The instruction went into 
effect for services furnished on or after July 1, 2005, and therefore, 
was in effect for the last 6 months of CY 2005. Thus, we expect

[[Page 68148]]

that the reporting of charges and units for blood and blood products in 
CY 2005 has improved over past years, especially with respect to 
hospitals' inclusion of all charges related to the acquisition, 
processing, and handling of blood and blood products as specifically 
described in each of the relevant HCPCS P-code descriptors. We believe 
that the median costs for blood and blood products from the CY 2005 
claims data reflect this improved reporting of charges and units for 
these products, particularly with regard to the most commonly furnished 
blood and blood products.
    Of the 34 blood products, median costs per unit (calculated using 
the simulated blood-specific CCR methodology) for CY 2007 rise for 23 
of them compared to their CY 2006 unadjusted simulated median unit 
costs. These 23 products account for about 82 percent of all units of 
blood products furnished to Medicare beneficiaries in the hospital 
outpatient department in our CY 2005 claims data. As has been the case 
in the past, the low volume products (which we have historically 
defined as fewer than 1,000 units per year) show the most volatility. 
Of the 11 low volume products, 6 products show increases in their unit 
costs compared to their CY 2006 unadjusted simulated median unit costs, 
and 5 products show decreases in their median unit costs compared to 
their CY 2006 unadjusted simulated median unit costs. The low volume 
products for which the median costs decline compared to their 
unadjusted simulated median costs in CY 2006 represent only 0.48 
percent of the total units of blood products furnished in the CY 2005 
OPPS claims data.
    However, we recognize that for some blood products, including one 
product that is not of low volume, the difference between the CY 2006 
adjusted simulated median cost on which CY 2006 payment is based is 
greater than 25 percent. Therefore, we are providing a transitional 
payment for CY 2007 by limiting the amount of the decrease for CY 2007 
compared to CY 2006 to no more than 25 percent. We believe that this is 
a necessary and appropriate step in the transition to payments for 
blood and blood products based fully on claims data.
    Fewer blood products actually experience increases in their median 
costs from CY 2006 to their final CY 2007 median costs because we 
adjusted the CY 2006 median costs for blood and blood products. Of the 
34 blood products, median costs rise for 18 of them compared to the CY 
2006 OPPS adjusted simulated median costs on which the CY 2006 payments 
are based (and which were adjusted to no less than 95 percent of the CY 
2005 payment medians). These 18 products account for 81 percent of all 
units of blood products furnished in our CY 2005 claims data. Of the 11 
low volume products, 3 show increases in their median unit costs 
compared to the CY 2006 OPPS adjusted simulated median unit costs, and 
8 show decreases compared to their CY 2006 OPPS adjusted simulated 
median unit costs. The low volume products that show a decline in 
medians compared to their CY 2006 adjusted simulated median costs 
represent only 0.37 percent of the total units of blood products 
reflected in the CY 2005 claims data.
    In summary, we are setting the final payment rates for blood and 
blood products for CY 2007 based on the unadjusted simulated median 
costs for blood and blood products that are derived from CY 2005 claims 
data as we have described, with the exception of the seven products for 
which we are providing a payment adjustment to smooth their transition 
to full claims-based payment in the future. We believe that, in most 
cases, the unadjusted median unit costs developed by this process are 
valid reflections of the estimated median costs of furnishing these 
specific blood products, and that no adjustment is required to result 
in appropriate payments for blood and blood products in CY 2007. Under 
this policy, based on the CY 2005 claims data, the projected payments 
will rise for approximately 81 percent of the blood product units paid 
under the OPPS if patterns of furnishing blood products in CY 2007 
remain similar to those in CY 2005. The low volume products whose 
simulated median costs decline compared to their CY 2006 adjusted 
simulated median costs are furnished very rarely and by very few 
providers because, in part, more commonly available products may be 
used for similar clinical indications. In addition, the median costs of 
several low volume blood products show a significant increase for CY 
2007.
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XI. OPPS Payment for Observation Services

    Observation care is a well-defined set of specific, clinically 
appropriate services that include ongoing short-term treatment, 
assessment, and reassessment before a decision can be made regarding 
whether patients will require further treatment as hospital inpatients 
or if they are able to be discharged from the hospital. Observation 
status is commonly assigned to patients with unexpectedly prolonged 
recovery after surgery and to patients who present to the emergency 
department and who then require a significant period of treatment or 
monitoring before a decision is made concerning their next placement.
    For CY 2006, we adopted two coding changes that affect how 
observation services are reported, and we made changes in the OCE to 
shift from individual providers to the OPPS claims processing systems 
the determination of whether or not observation services are separately 
payable or packaged. Observation services reported using HCPCS code 
G0378 (Hospital observation services, per hour) that are eligible for 
separate payment map to APC 0339 (Observation). The CY 2006 payment 
rate for APC 0339 is $425.08.
    In the CY 2007 proposed rule, we proposed a CY 2007 median cost for 
APC 0339 of $442.16. This reflected relative stability in hospital 
costs for separately payable observation care. Direct admission to 
observation (HCPCS code G0379), when separately payable, is currently 
assigned for payment to APC 0600 (Low Level Clinic Visit) with a CY 
2006 payment rate of $52.37. As discussed below, for CY 2007, we 
proposed to assign direct admission to observation, when separately 
payable, to APC 0604 (Low Level Clinic Visit). The proposed CY 2007 
median cost for APC 0604 was $49.93.
    As we stated in the CY 2006 OPPS final rule with comment period (70 
FR 68688), the changes that we adopted for CY 2006 were intended to 
ensure more consistent hospital billing for observation services in 
order to guide our future analyses of payment for observation care and 
to simplify how observation services are reported and paid. We refer 
readers to the CY 2006 OPPS final rule with comment period for a 
detailed discussion of the G-codes for observation services and the OCE 
logic changes implemented for CY 2006 (70 FR 68688), and to Program 
Transmittal 787, issued on December 16, 2005, in which we updated 
Chapter 4, Section 290 of the Medicare Claims Processing Manual (Pub. 
100-04) to reflect the CY 2006 changes and to provide additional 
guidance to contractors and hospitals.
    During the APC Panel's March 2006 meeting, the Observation 
Subcommittee did not make any recommendations to the Panel other than 
to request its review of additional data on observation services at the 
Panel's 2007 winter meeting. The APC Panel adopted the Observation 
Subcommittee's report and recommended no changes to the criteria for 
separate payment for observation services or to the coding and payment 
methodology for observation services.
    During the APC Panel's August 2006 meeting, the Observation 
Subcommittee made several recommendations regarding observation 
services. The first of these was that CMS should consider adding 
syncope and dehydration as diagnoses for which observation services 
would qualify for separate payment. Second, the Observation 
Subcommittee recommended that CMS perform claims analyses and present 
data that would allow it to consider revising criteria for separately 
payable observation services when certain procedures that are assigned 
status indicator ``T,'' for example, insertion of a bladder catheter or 
laceration repair, are reported on the same claim with an emergency 
department visit and observation services, and all other criteria for 
separate observation payment (for example, qualifying diagnosis code, 
number of hours) are met.
    Comment: A few commenters expressed ongoing support for the 
improved processing of observation claims through use of the OCE to 
assign separate or packaged status to observation services depending on 
whether the criteria for separate payment were met, an approach that 
CMS implemented for CY 2006. The commenters suggested that now that CMS 
has simplified the process for ensuring separate payment for covered 
outpatient observation services in specific circumstances, CMS should 
consider adding syncope and dehydration as diagnoses that qualify for 
separate observation payment. The commenters did not request CY 2007 
implementation, but, rather, their suggestions were consistent with the 
APC Panel recommendation that CMS should explore this expansion to the 
list of diagnoses for which observation may be separately paid.
    Also related to the APC Panel recommendations, one commenter 
recommended that CMS perform claims and data analysis that would enable 
CMS to consider revising the criteria for separately payable 
observation services when certain procedures that are assigned status 
indicator ``T'' are reported on the same claim with an emergency 
department visit and observation services, and all other criteria for 
separate observation payment are met.
    Response: We intend to perform a series of analyses over the 
upcoming year to explore the potential effects of adding syncope and 
dehydration as qualifying diagnoses for separately payable observation 
services, as well as the possibility of allowing separate observation 
payment for claims for observation services that also include specific 
minor or routine procedures that have ``T'' status indicators. We will 
continue to work with the APC Panel Observation Subcommittee over the 
coming months in response to these recommendations. We expect to have 
preliminary results of the analyses in time for discussion with the 
full Panel at the next APC Panel meeting in the winter of 2007.
    For CY 2007, as we proposed, we are continuing to apply the 
criteria for separate payment for observation services and the coding 
and payment methodology for observation services that were implemented 
in CY 2006, with one exception. In section IX. of this preamble, we are 
making final changes in APC assignments and payments for clinic and 
emergency department visits. As part of those changes, low level clinic 
visits are being moved from APC 0600 (Low Level Clinic Visits) to APC 
0604 (Level 1 Clinic Visits), with a final CY 2007 median cost of 
$50.37. Under the circumstances where direct admission to observation 
is separately payable, we are finalizing our assignment of HCPCS code 
G0379 to APC 0604, consistent with its CY 2006 placement in the APC for 
Low Level Clinic Visits.
    Comment: One commenter suggested that CMS adopt ``midnight'' as a 
defining measure of an overnight stay in hospital outpatient 
departments. The commenter believed that CMS proposed to apply that 
definition of an overnight stay in ASCs so beneficiaries in ASCs at 
midnight would be transferred at that time to hospital outpatient 
departments for continuing care. The commenter stated that those 
patients would be unlikely to meet acuity and severity requirements for 
inpatient admission and would be admitted to observation and that the 
hospital would be able to bill for the initial care with G0379 because 
the patient was a direct admission. The commenter expressed concern 
about the payment inequity between the situation in which a patient is 
transferred to observation from the

[[Page 68151]]

ASC (and the hospital can bill for direct admission to observation) 
compared to that for patients who are transferred from the hospital's 
own outpatient department into observation (and the hospital cannot 
bill).
    The commenter suggested that CMS consider a new source of admission 
code for ``transfer from ASC'' to be used by hospitals. The commenter 
believed that CMS would benefit from collection of that data.
    Response: We believe the commenter has misinterpreted our proposed 
use of midnight to define an overnight stay in ASCs for CY 2008. There 
is no requirement for an ASC to transfer a patient who continues to 
require care at and beyond midnight. For implementation in CY 2008, we 
proposed to include on the list of procedures for which an ASC facility 
fee would be allowed any procedure that may be safely performed in the 
ASC and that does not require an overnight stay. We proposed to exclude 
from payment of an ASC facility fee any procedure for which prevailing 
medical practice dictates that the beneficiary would typically be 
expected to require active medical monitoring at midnight following the 
procedure (71 FR 49638). Therefore, midnight with respect to an 
overnight stay is used solely for determining which procedures are 
eligible to be included on the Medicare ASC list and, thus, payment of 
an ASC facility fee would be allowed. There is no requirement to 
transfer patients out of the ASC at midnight.
    Our proposed use of midnight to define overnight stay for purposes 
of evaluating procedures for inclusion on the Medicare ASC list has no 
payment implications for the hospital outpatient department. The 
proposal is still open for comment and, therefore, we will make no 
final decision about the proposal at this time.
    As the commenter pointed out, in the circumstances where a patient 
is transferred from an ASC to a hospital for observation, the hospital 
may report HCPCS code G0379 (Direct admission of patient for hospital 
observation care) for the direct admission to observation service, 
along with HCPCS code G0378 for the hours of observation care. However, 
unless the observation services meet our criteria for separate payment, 
the hospital would only receive separate payment for HCPCS code G0379 
through APC 0604 (Level 1 Clinic Visits), with a CY 2007 median cost of 
about $50. Similarly, if a patient has an outpatient surgical procedure 
performed in a hospital and requires outpatient observation care after 
the recovery period, the hospital may report the hours of observation 
using HCPCS code G0379, with payment for the observation care packaged 
into payment for the surgical procedure. We believe that the current 
policy is reasonable because, in both cases, hospitals will receive a 
separate payment for their services, into which payment for the hours 
of observation care is packaged.
    Comment: One commenter sought clarification on whether the CY 2007 
median cost calculation for APC 0339 included claims with more than 48 
hours of observation. The commenter also sought clarification about 
whether all hours of observation care beyond 48 hours are noncovered.
    Response: As we have stated before in reference to the appropriate 
duration of observation services, we believe that in the overwhelming 
majority of cases, decisions can be and are routinely made in less than 
24 hours, regarding whether to release a beneficiary from the hospital 
following resolution of the reason for the outpatient visit or whether 
to admit the beneficiary as an inpatient. Again, as we have stated 
repeatedly, all hospital observation services, regardless of the 
duration of the observation care, that are medically reasonable and 
necessary are covered by Medicare, and hospitals receive either 
packaged or separate OPPS payment for these covered observation 
services. Similar to CY 2006, in calculation of the CY 2007 median cost 
for APC 0339, we used all claims for G0244 (Observation care provided 
by a facility to a patient with CHF, chest pain, or asthma, minimum 
eight hours), the HCPCS code that hospitals used in CY 2005 to report 
hour of separately payable observation under the circumstances 
described by the code. Because this code was only to be reported for 
observation care that spanned a minimum of 8 hours, we used all claims 
for G0244 in our median cost calculation for APC 0339 for CY 2007, 
regardless of the number of units of G0244 reported.
    As we stated in Program Transmittal A-02-129 released in January 
2003, we will continue to include in the October quarterly update of 
the OPPS any changes to the list of ICD-9-CM codes required for 
separate payment of HCPCS code G0378 resulting from the October 1 
annual update of ICD-9-CM codes. The applicable ICD-9-CM codes for 
separate payment for observation services under the CY 2007 OPPS are 
listed in Table 44 below.
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XII. Procedures That Will Be Paid Only as Inpatient Procedures

A. Background

    Section 1833(t)(1)(B)(i) of the Act gives the Secretary broad 
authority to determine the services to be covered and paid for under 
the OPPS. Before implementation of the OPPS in August 2000, Medicare 
paid reasonable costs for services provided in the outpatient 
department. The claims submitted were subject to medical review by the 
fiscal intermediaries to determine the appropriateness of providing 
certain services in the outpatient setting. We did not specify in 
regulations those services that were appropriate to provide only in the 
inpatient setting and that, therefore, should be payable only when 
provided in that setting.
    In the April 7, 2000 final rule with comment period, we identified 
procedures that are typically provided only in an inpatient setting 
and, therefore, would not be paid by Medicare under the OPPS (65 FR 
18455). These procedures comprise what is referred to as the 
``inpatient list.'' The inpatient list specifies those services that 
are only paid when provided in an inpatient setting because of the 
nature of the procedure, the need for at least 24 hours of 
postoperative recovery time or monitoring before the patient can be 
safely discharged, or the underlying physical condition of the patient. 
As we discussed in the April 7, 2000 final rule with comment period (65 
FR 18455) and the November 30, 2001 final rule (66 FR 59856), we use 
the following criteria when reviewing procedures to determine whether 
or not they should be moved from the inpatient list and assigned to an 
APC group for payment under the OPPS:
     Most outpatient departments are equipped to provide the 
services to the Medicare population.
     The simplest procedure described by the code may be 
performed in most outpatient departments.
     The procedure is related to codes that we have already 
removed from the inpatient list.
    In the November 1, 2002 final rule with comment period (67 FR 
66741), we removed 43 procedures from the inpatient list for payment 
under OPPS. We also added the following criteria for use in reviewing 
procedures to determine whether they should be removed from the 
inpatient list and assigned to an APC group for payment under the OPPS:
     We have determined that the procedure is being performed 
in numerous hospitals on an outpatient basis; or
     We have determined that the procedure can be appropriately 
and safely performed in an ambulatory surgical center (ASC) and is on 
the list of approved ASC procedures or proposed by us for addition to 
the ASC list.
    We believe that these additional criteria help us to identify 
procedures that are appropriate for removal from the inpatient list.

B. Changes to the Inpatient List

    For the CY 2007 OPPS, we used the same methodology as described in 
the November 15, 2004 final rule with comment period (69 FR 65835) to 
identify a subset of procedures currently on the inpatient list that 
are being widely performed on an outpatient basis. These procedures 
were then clinically reviewed for possible removal from the inpatient 
list. We solicited input from the APC Panel on the appropriateness of 
the removal of seven procedures from the inpatient list at the March 1, 
2006 APC Panel meeting. Prior to publishing the CY 2007 OPPS proposed 
rule, we had not received any other candidate HCPCS codes for removal 
from the OPPS inpatient list based on recommendations from the public. 
The APC Panel recommended that one of the procedures (CPT code 21181, 
Reconstruction by contouring of benign tumor of cranial bones, 
extracranial) be removed from the list, and that we solicit approval 
from the relevant physician specialty societies prior to proposing 
removal of the other six procedures. For CY 2007, we ultimately 
proposed to remove a total of eight procedures from the inpatient list.
    Consistent with our established policy for removing procedures from 
the inpatient list, we rely on our utilization data and clinical staff 
input in determining which procedures are candidates for removal. We 
believe that our policy of proposing the procedures for removal and 
soliciting comments from the public, which includes physician specialty 
societies, is the most appropriate process to receive input from the 
public on this issue. Rather than solicit approval from a select group 
(for example, specific physician specialty societies), in the CY 2007 
proposed rule we solicited comments from all interested parties 
consistent with meeting our obligation to the public regarding 
outpatient services provided by hospitals.
    During the APC Panel meeting in August 2006, a presenter requested 
that the Panel recommend to CMS removal of 10 procedures from the 
inpatient list for CY 2007, in addition to those presented in the 
proposed rule. The 10 procedure codes and their descriptors are 
displayed in Table 45 below. The APC Panel recommended that CMS remove 
the procedures from the inpatient list and assign them to appropriate 
clinical APCs for payment beginning in CY 2007, including considering 
their assignment to APCs for female reproductive procedures such as 
APCs 0194 (Level VIII Female Reproductive Proc), 0195 (Level IX Female 
Reproductive Proc), and 0202 (Level X Female Reproductive Proc).

    Table 45.--Additional Procedures Recommended by the APC Panel for
               Removal From the Inpatient List for CY 2007
------------------------------------------------------------------------
            HCPCS  Code                        Long Descriptor
------------------------------------------------------------------------
57282.............................  Colpopexy, vaginal; extra-peritoneal
                                     approach (sacrospinous,
                                     iliococcygeus).
57283.............................  Colpopexy, vaginal; intra-peritoneal
                                     approach (uterosacral, levator
                                     myorrhaphy).
58260.............................  Vaginal hysterectromy, for uterus
                                     250 grams or less.
58262.............................  Vaginal hysterectomy, for uterus 250
                                     grams or less; with removal of
                                     tube(s) and/or ovary(s).
58263.............................  Vaginal hysterectomy, for uterus 250
                                     grams or less; with removal of
                                     tube(s), and/or ovary(s), with
                                     repair of enterocele.
58270.............................  Vaginal hysterectomy, for uterus 250
                                     grams or less; with repair of
                                     enterocele.
58290.............................  Vaginal hysterectomy, for uterus
                                     greater than 250 grams.
58291.............................  Vaginal hysterectomy, for uterus
                                     greater than 250 grams; with
                                     removal of tube(s) and/or ovary(s).
58292.............................  Vaginal hysterectomy, for uterus
                                     greater than 250 grams; with
                                     removal of tube(s) and/or ovary(s),
                                     with repair of enterocele.

[[Page 68155]]

 
58294.............................  Vaginal hysterectomy, for uterus
                                     greater than 250 grams; with repair
                                     of enterocele.
------------------------------------------------------------------------

    We received numerous comments on our inpatient list proposal for 
the CY 2007 OPPS. A summary of the public comments and our responses 
follow:
    Comment: Several commenters supported the APC Panel's 
recommendation made during its August 2006 meeting to remove the 10 
procedures listed in Table 45 above.
    Response: Although the most recent physician utilization data 
indicate that the procedures are performed on an inpatient basis 80 to 
95 percent of the time, most of them have low volumes. We agree with 
the presenter and the APC Panel that they are performed predominantly 
for the younger women in our beneficiary population and, therefore, we 
believe they may be safely performed in the outpatient department. 
Therefore, we are removing the procedures as listed in Table 45 above 
from the OPPS inpatient list and assigning them to appropriate clinical 
APCs for CY 2007 as noted in Table 46 of this final rule with comment 
period.
    Comment: Many commenters recommended elimination of the inpatient 
list altogether. Some of the commenters suggested that CMS rely on the 
Quality Improvement Organizations (QIOs) to handle issues related to 
care provided in inappropriate settings instead of maintaining the 
inpatient list, and all of the commenters believed that the decision to 
admit a beneficiary to the hospital should be left to the physician. 
They explained that the inpatient list causes confusion for hospitals 
when they are trying to make decisions about the medical necessity of 
admission for beneficiaries.
    In addition, the commenters suggested that, if CMS does not 
eliminate the list, CMS should post the inpatient list and an 
explanation of its purpose on CMS' Web page for physicians and 
carriers, and that CMS present that same educational information during 
the Physician Open Door Forum. Further, a number of the commenters 
suggested that CMS consider implementing an appeals process to allow 
providers to submit documentation about physician intent, patient 
clinical condition, and the circumstances that allowed the patient to 
be sent home safely without an inpatient admission after payment has 
been denied because the procedure performed in the outpatient 
department was on the inpatient list.
    Response: We appreciate these comments and thoughtful suggestions. 
We continue to believe that the inpatient list is a valuable tool that 
is appropriate for the OPPS, and we will not eliminate it at this time. 
We believe there are many surgical procedures that are never safely 
performed for typical Medicare beneficiaries in the hospital outpatient 
setting, so that it would be inappropriate for us to assign them 
separately payable status indicators and establish payment rates in the 
OPPS. However, we welcome the commenters' suggestions to provide more 
education to physicians about the list and its purpose. We intend to 
put those suggestions into practice. However, we will not implement an 
appeals process at this time.
    Comment: One commenter recommended that CMS not remove CPT code 
22851 (Application of intervertebral biomechanical device(s)(eg, 
synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to 
vertebral defect or interspace), 22612 (Arthrodesis, posterior or 
posterolateral technique, single level; lumbar), or 22614 (Arthrodesis, 
posterior or posterolateral technique, single level; each additional 
vertebral segment) from the inpatient list. The commenter stated that 
CPT code 22851 should not be removed as CMS proposed because the 
primary procedures with which it is performed (CPT codes 22325 (Open 
treatment and/or reduction of vertebral fracture(s) and/or 
dislocation(s), posterior approach, one fractured vertebrae or 
dislocated segment; lumbar); 22326 (Open treatment and/or reduction of 
vertebral fracture(s) and/or dislocation(s), posterior approach, one 
fractured vertebrae or dislocated segment; cervical); and 22327 (Open 
treatment and/or reduction of vertebral fracture(s) and/or 
dislocation(s), posterior approach, one fractured vertebrae or 
dislocated segment; thoracic) are still on the inpatient list. The 
commenters believed that, even though CPT codes 22612 and 22614 were 
removed from the list in 2003, they should be put back on the inpatient 
list because the autologous and allograft bone graft procedures with 
which they are provided are still on the inpatient list.
    Response: We proposed to remove CPT code 22851 because we believed 
that it was being performed safely in the outpatient setting. CPT code 
22851 is not used exclusively with the CPT codes cited by the 
commenter. In fact, in our consultation with physician experts, we 
found that it is being performed safely in the outpatient setting, but 
not with the procedures that are on the inpatient list.
    We are confident after our additional medical consultation that 
proposing to remove CPT code 22851 from the inpatient list was 
appropriate. Therefore, we are finalizing our proposal, without 
modification, to remove CPT code 22851 from the inpatient list for CY 
2007.
    We have received no comments prior to this year requesting that we 
put CPT codes 22612 and 22614 back on the inpatient list. Both of the 
procedures are performed 99 percent of the time in the inpatient 
setting, even though they are no longer on the inpatient list. We have 
a small number of outpatient hospital claims for both CPT codes from CY 
2005. We have not seen significant growth in the outpatient performance 
of these procedures since they were removed the inpatient list several 
years ago. This is consistent with our belief that these procedures are 
being performed in the most appropriate setting, and we see no reason 
to reassign them to the inpatient list. Therefore, we are finalizing 
our proposal without modification and are not adding CPT codes 22612 
and 22614 to the inpatient list for CY 2007.
    Comment: One commenter requested that CMS not finalize the proposal 
to remove CPT code 61720 (Creation of lesion by stereotactic method, 
including burr hole(s) and localizing and recording techniques, single 
or multiple stages; globus pallidus or thalamus). The commenter stated 
that they have received feedback from physicians that it would not be 
clinically appropriate to perform the procedure in an outpatient 
setting. The commenter stated that requiring at least an overnight stay 
is the standard of care for the procedure. The commenter noted that the 
APC Panel recommended that CMS consult with the relevant specialty 
society to confirm

[[Page 68156]]

the appropriateness of removing the code from the inpatient list and 
stated that it was not clear in the proposed rule whether that 
confirmation was made.
    Response: In our proposed rule, we clearly stated that we were 
interested in comments from the public on our proposals to remove codes 
from the inpatient list. We also stated that our solicitation of 
comments from the public includes physician specialty societies. 
Further, we explained that rather than solicit approval from a select 
group (physician specialty societies), we believed that solicitation of 
comments from interested parties was more consistent with meeting our 
obligation to the public.
    We note that aside from this one comment, we received no other 
responses to our proposal. We would have expected that the physicians 
who were concerned enough about our proposed removal of CPT code 61720 
from the inpatient list that they discussed it with the commenter would 
have conveyed their concerns directly to us as well. Thus, we have no 
other information outside of the commenter's assertion to confirm this 
procedure requires an inpatient stay.
    The procedure coded as CPT code 61720 is performed only 26 percent 
of the time in the inpatient setting. We continue to believe that 
removing the procedure from the inpatient list is appropriate, and we 
are finalizing our proposal to do so, without modification.
    Comment: One commenter requested that CMS remove three additional 
procedures, CPT code 37182 (Insertion of transvenous intrahepatic 
portosystemic shunt(s)(TIPS)(includes venous access, hepatic and portal 
vein catheterization, portography with hemodynamic evaluation, 
intrahepatic tract formation/dilatation, stent placement and all 
associated imaging guidance and documentation)); 45563 (Exploration, 
repair, and presacral drainage for rectal injury; with colostomy); and 
61624 (Transcatheter permanent occlusion or embolization (eg, tumor 
destruction, to achieve hemostasis, to occlude a vascular 
malformation), percutaneous, any method; central nervous system 
(intracranial, spinal cord)) from the inpatient list. The commenter 
provided no rationale for requesting the removal of those procedures.
    Response: The utilization data for these codes show that all of 
them are performed more than 80 percent of the time on an inpatient 
basis. While we first removed the CPT code for the revision TIPS 
procedure (CPT code 37183) from the inpatient list for CY 2006, our 
decision was based, in part, on a recommendation of the APC Panel to do 
so. We will be following OPPS claims data for that procedure based upon 
its newly payable status under the OPPS. However, without specific 
clinical evidence that the initial TIPS procedure and the other 
procedures recommended by the commenter may be safely performed in the 
hospital outpatient setting, we believe that it is appropriate to 
retain those procedures on the inpatient list. Therefore, we are 
finalizing our CY 2007 proposal, without modification, to retain these 
three services on the inpatient list.
    Comment: One commenter requested that CMS remove two procedures, 
CPT codes 60502 ( Parathyroidectomy or exploration of thyroid(s); re-
exploration) and 60520 (Thymectomy, partial or total; transcervical 
approach), from the OPPS inpatient list. The commenter stated that 
those procedures are often performed in the same operative session with 
CPT code 60500 (Parathyroidectomy or exploration of thyroid(s)), which 
is not included on the inpatient list. The commenter believed that the 
two procedures (CPT codes 60502 and 60520) may be safely performed in 
the hospital outpatient department and should be removed from the 
inpatient list.
    Response: We reviewed the outpatient hospital claims data and Part 
B physician bill data for CPT codes 60502 and 60520. According to the 
Part B bill data, CPT code 60502 was performed 43 percent of the time 
in the hospital outpatient setting in CY 2005, and CPT code 65020 was 
performed 27 percent of the time in that setting. Although there were 
very few single procedure claims in the OPPS data for these two 
procedure codes, we did find 12 single procedure claims for CPT code 
60502 with a median cost of approximately $2,715.
    Taking into account the utilization information, hospital data, 
cost data, and the advice of our medical advisors, we believe that it 
is appropriate to remove the two procedures from the inpatient list. 
Therefore, for CY 2007 we will assign CPT codes 60502 and 60520 to APC 
0256 (Level V ENT Procedures), the same APC to which CPT code 60500 is 
assigned. We will monitor utilization and evaluate the assignments of 
these codes to APC 0256 as data become available to us (in time for the 
CY 2009 proposed rule) and as we do for all procedures after making 
changes in their APC assignments.
    Consistent with our CY 2007 proposal, the utilization data and 
clinical review findings for the eight procedures support our removal 
of them from the inpatient list. We also are accepting the APC Panel's 
recommendation regarding the removal of 10 additional procedures from 
the inpatient list for CY 2007 and the public comment requests that we 
remove 2 other procedures. Therefore, we are removing a total of 20 
procedures from the inpatient list and assigning them to clinically 
appropriate APCs, as shown in Table 46. The changes to the inpatient 
list will be effective for services furnished on or after January 1, 
2007.

    Table 46.--Procedure Codes Removed From Inpatient List and New APC Assignments, Effective January 1, 2007
----------------------------------------------------------------------------------------------------------------
                                                                                  CY 2007  APC   CY 2007  Status
                HCPCS  code                            Long Descriptor             Assignment       Indicator
----------------------------------------------------------------------------------------------------------------
16035......................................  Escharotomy; initial incision.....            0016               T
21181......................................  Reconstruction by contouring of               0254               T
                                              benign tumor of cranial bones,
                                              extracranial.
 22851.....................................   Apply spine prosth device........            0049               T
 57282.....................................   Colpopexy, vaginal; extra-                   0202               T
                                              peritoneal approach
                                              (sacrospinous, iliococcygeus).
57283......................................  Colpopexy, vaginal; intra-                    0202               T
                                              peritoneal approach (uterosacral,
                                              levator myorrhaphy).
57292......................................  Construction of artificial vagina;            0195               T
                                              with graft.
57335......................................  Vaginoplasty for intersex state...            0195               T
58260......................................  Vaginal hysterectromy, for uterus             0195               T
                                              250 grams or less.

[[Page 68157]]

 
58262......................................  Vaginal hysterectomy, for uterus              0195               T
                                              250 grams or less; with removal
                                              of tube(s) and/or ovary(s).
58263......................................  Vaginal hysterectomy, for uterus              0195               T
                                              250 grams or less; with removal
                                              of tube(s), and/or ovary(s), with
                                              repair of enterocele.
58270......................................  Vaginal hysterectomy, for uterus              0195               T
                                              250 grams or less; with repair of
                                              enterocele.
58290......................................  Vaginal hysterectomy, for uterus              0202               T
                                              greater than 250 grams.
58291......................................  Vaginal hysterectomy, for uterus              0202               T
                                              greater than 250 grams; with
                                              removal of tube(s) and/or
                                              ovary(s).
58292......................................  Vaginal hysterectomy, for uterus              0202               T
                                              greater than 250 grams; with
                                              removal of tube(s) and/or
                                              ovary(s), with repair of
                                              enterocele.
58294......................................  Vaginal hysterectomy, for uterus              0202               T
                                              greater than 250 grams; with
                                              repair of enterocele..
60502......................................  Parathyroidectomy or exploration              0256               T
                                              of thyroid(s); re-exploration.
60520......................................  Thymectomy, partial or total;                 0256               T
                                              transcervical approach.
61720......................................  Creation of lesion by stereotactic            0221               T
                                              method, including burr holes and
                                              localizing and recording
                                              techniques, single of multiple
                                              stages; globus pallidus or
                                              thalamus.
62000......................................  Elevation of depressed skull                  0254               T
                                              fracture; simple extradural.
64804......................................  Sympathectomy, cervicothoracic....            0220               T
----------------------------------------------------------------------------------------------------------------

C. CY 2007 Payment for Ancillary Outpatient Services When Patient 
Expires (-CA Modifier)

1. Background
    In the November 1, 2002 final rule with comment period (67 FR 
66798), we discussed the creation of a new HCPCS modifier -CA to 
address situations where a procedure on the OPPS inpatient list must be 
performed to resuscitate or stabilize a patient (whose status is that 
of an outpatient) with an emergent, life-threatening condition, and the 
patient dies before being admitted as an inpatient. In Transmittal A-
02-129, issued on January 3, 2003, we instructed hospitals on the use 
of this modifier when submitting a claim on bill type 13x for a 
procedure that is on the inpatient list and assigned the payment status 
indicator (SI) ``C'' (to indicate inpatient services that are not paid 
under the OPPS). Conditions to be met for hospital payment for a claim 
reporting a service billed with modifier -CA include a patient with an 
emergent, life-threatening condition on whom a procedure on the 
inpatient list is performed on an emergency basis to resuscitate or 
stabilize the patient. For CY 2003, a single payment for otherwise 
payable outpatient services billed on a claim with a procedure appended 
with this new -CA modifier was made under APC 0977 (New Technology 
Level VIII, $1,000-$1,250), due to the lack of available claims data to 
establish a payment rate based on historical hospital costs.
    As discussed in the November 7, 2003 final rule with comment 
period, we created APC 0375 (Ancillary Outpatient Services When Patient 
Expires) to pay for services furnished on the same date as a procedure 
with SI ``C'' and billed with the modifier -CA (68 FR 63467) because we 
were concerned that payment under a New Technology APC would not result 
in an appropriate payment. Payment under a New Technology APC is a 
fixed amount that does not have a relative payment weight and, 
therefore, is not subject to recalibration based on hospital costs. In 
the absence of hospital claims data to determine costs, the clinical 
APC 0375 payment rate for CY 2004 was set at $1,150, which was the 
payment amount for the newly structured New Technology APC that 
replaced APC 0977.
    For CYs 2005 and 2006, the payment rates for APC 0375 for services 
billed on the same date as a ``C'' status procedure appended with 
modifier -CA were established in accordance with the same methodology 
we followed to set payment rates for the other procedural APCs in those 
years, based on the relative payment weight calculated for APC 0375. 
For APC 0375 specifically, we calculated the relative payment weight 
from all claims reporting a ``C'' status procedure appended with 
modifier -CA, using charge data from the relevant calendar year claims 
for line items with a HCPCS code and status indicator ``V,'' ``S,'' 
``T,'' ``X,'' ``N,'' ``K,'' ``G,'' and ``H,'' in addition to charges 
for revenue codes without a HCPCS code. We continued to make one 
payment in CYs 2005 and 2006 under APC 0375 for the services that met 
the specific conditions discussed in previous rules for using modifier 
-CA.
    In the CY 2006 final rule with comment period (70 FR 68700), we 
discussed our concern about the large increase in the volume of 
hospital claims billed with modifier -CA from CY 2003 to CY 2004, 
growing from 18 to 300 claims over that 1-year time period. We 
acknowledged that because modifier -CA was first introduced for CY 
2003, the use of the modifier in CYs 2003 and 2004 may have reflected 
such an increase due to hospitals' learning curve with respect to the 
modifier's appropriate use on claims for services payable under the 
OPPS. We also expressed some concern that numerous claims reflected 
unanticipated examples of ``C'' status procedures reported with 
modifier -CA that may not have been provided to patients with emergency 
life threatening conditions, where the inpatient procedure was 
performed on an emergency basis to resuscitate or stabilize the 
patient. We promised to monitor CY 2005 claims data for similar 
increases.
    Our review of the CY 2005 claims data available for the CY 2007 
proposed rule revealed a decrease in the use of modifier -CA in 
comparison with CY 2004 claims. In the final CY 2005 data available for 
this final rule with comment period, there were 260 claims submitted 
reporting modifier -CA. Because of the diverse individual clinical 
scenarios where modifier -CA may be appropriately reported, we expect 
some variation from year to year

[[Page 68158]]

in the number of OPPS claims reporting the modifier and in light of the 
growth in outpatient claims overall, it is encouraging that the level 
of claims with -CA modifier decreased compared to CY 2004. It would 
appear that the hospital learning curve regarding use of modifier -CA 
may have been completed over the past 3-year period, and that we may 
expect relatively consistent reporting of this modifier in future 
years. We note that not only was there no increase in the number of 
claims reporting modifier -CA in CY 2005, but there were also fewer 
apparently inappropriate instances of use. Our CY 2005 claims data show 
the majority of reporting of modifier -CA was in association with what 
were likely to have been urgent interventions, including the insertion 
of intra-aortic balloon assist devices and exploratory laparotomies. We 
believe that the data support our speculation that much of the increase 
in reporting of the modifier observed in CY 2004 data was a result of 
hospitals' learning curve regarding the appropriate use of the 
modifier.
2. Policy for CY 2007
    In the CY 2007 OPPS proposed rule (71 FR 49622), we did not propose 
any change to our policies regarding reporting of modifier -CA for CY 
2007, or to our payment policy regarding APC 0375. Therefore, for CY 
2007, as we proposed, we are specifying that hospitals continue 
reporting modifier -CA only under circumstances described in section 
VI. of Transmittal A-02-129, which provided specific billing guidance 
for the use of modifier -CA. In addition, we will continue to make one 
payment under APC 0375 for the services that meet the specific 
conditions discussed in previous rules for using modifier -CA, based on 
calculation of the relative payment weight for APC 0375 as described 
above. We applaud hospitals' improved billing practices and as before, 
will continue to monitor use of modifier -CA.
    The CY 2007 proposed APC 0375 median cost was $3,539, significantly 
increased from the $2,527 median cost in the CY 2006 proposed rule and 
the CY 2006 final median cost of $2,717. The CY 2007 final APC 0375 
median cost is $3,549. This variation in median costs is expected 
because the specific cases that populate the claims data for APC 0375 
likely exhibit only limited clinical and resource homogeneity among all 
the claims attributable to that APC in a given year and across 
different years for the same APC. Such cost variation for APC 0375 from 
year to year is generally anticipated and accepted because APC 0375 is 
unique in the OPPS and, by its definition, should always be limited in 
its use.
    We did not receive any public comments on our proposed payment 
policy for ancillary outpatient services when a patient expires. 
Therefore, we are finalizing our proposal without modification for CY 
2007.

XIII. Nonrecurring Policy Changes

A. Removal of Comprehensive Outpatient Rehabilitation Facility (CORF) 
Services From the List of Services Paid Under the OPPS

    In the CY 2007 OPPS proposed rule (71 FR 49623), we proposed to 
make a technical change to the regulations at 42 CFR 419.21(d) to 
remove from the list of services paid under the OPPS certain services 
furnished by a comprehensive outpatient rehabilitation facility (CORF) 
when they are provided outside the patient's plan of care (for example, 
hepatitis B vaccine). Section 1834(k) of the Act, as added by section 
4541(a) of Public Law 105-33 (BBA), requires that CORF services be paid 
using the lesser of actual charges or a fee schedule amount. We 
instructed fiscal intermediaries to use the MPFS for payments to CORFs. 
We have not required CORF cost reports, or paid CORFs under the OPPS, 
since 2001. The revision of the regulation to delete certain CORF 
services from the list of specified services paid under the OPPS is 
necessary to conform the regulations to the statutory requirement.
    We did not receive any public comments on this issue. Therefore, we 
are adopting as final, without modification, the technical change to 
Sec.  419.21(d) to remove from the list of services paid under the OPPS 
certain services furnished by a CORF when they are provided outside the 
patient's plan of care (for example, hepatitis B vaccine).

B. Addition of Ultrasound Screening for Abdominal Aortic Aneurysms 
(AAAs) (Section 5112 of Public Law 109-171 (DRA))

1. Background
    Section 5112 of the Deficit Reduction Act of 2005, Public Law 109-
171 (DRA), amended section 1861 and related provisions of the Act to 
provide for coverage under Medicare Part B of ultrasound screening for 
abdominal aortic aneurysms (AAAs), effective for services furnished on 
or after January 1, 2007, subject to certain eligibility and other 
limitations. The final rule governing this new Part B coverage is being 
established through a separate document, specifically the CY 2007 
Medicare Physician Fee Schedule final rule. We refer readers to that 
document for a full and complete explanation of this coverage 
provision.
2. Assignment of New HCPCS Code and Payment for Ultrasound Screening 
for AAAs
    When we published the CY 2007 OPPS proposed rule, there was no 
current CPT code that specifically described an ultrasound screening 
for AAA. In that same rule, we proposed to establish the following 
HCPCS code, GXXXX (Ultrasound, B-scan and or real time with image 
documentation; for abdominal aortic aneurysm (AAA) screening) to be 
used to bill for the new service under both the Medicare Physician Fee 
Schedule and the OPPS. In this final rule with comment period, we are 
assigning HCPCS code G0389 (Ultrasound, B-scan and/or real time with 
image documentation; for abdominal aortic aneurysm (AAA) screening) to 
be reported on or after January 1, 2007, to describe an ultrasound 
screening test for AAA. As required by the statute, Medicare will allow 
payment for a one-time only screening examination, and this screening 
test will be available even if the qualifying patient does not present 
signs or symptoms of disease or illness. In addition, this code does 
not include any other preventive services that are currently separately 
covered and paid under the Medicare Part B screening benefits. When 
these other preventive services are performed, they should be reported 
using the existing appropriate codes.
    We noted previously that ultrasound screening for AAA is also 
addressed in detail in our final rule to update the MPFS for CY 2007. 
We are responding to all comments regarding the elements required for 
the ultrasound screening for AAA, whether the examination is performed 
in a physician's office or an outpatient hospital setting, and the 
exception from the Part B annual deductible, in the CY 2007 MPFS final 
rule.
    In the CY 2007 OPPS proposed rule, we proposed that payment for 
this service be made at the same level as CPT code 76775 (Ultrasound, 
retroperitoneal (eg, renal aorta modes), B-scan and/or real time with 
image documentation; limited).
    We received several comments on this payment proposal. In 
particular, the commenters supported the payment assignment of HCPCS 
code G0389. The commenters agreed that the hospital costs associated 
with the screening study described by HCPCS code G0389 are very similar 
to those of the limited retroperitoneal ultrasound diagnostic

[[Page 68159]]

examination, which is described by CPT code 76775. Therefore, in this 
final rule with comment period, we are finalizing this assignment for 
CY 2007. That is, we are basing the CY 2007 payment for HCPCS code 
G0389 on equivalent hospital resources and intensity to those contained 
in CPT code 76775, which is assigned to APC 0266 (Level II Diagnostic 
and Screening Ultrasound) under the OPPS for CY 2007. We believe that 
the hospital costs associated with the screening study are very similar 
to those of the limited retroperitoneal ultrasound diagnostic 
examination and, therefore, the screening and diagnostic studies should 
be assigned to the same clinical APC for reasons of clinical and 
resource homogeneity. Thus, we are assigning G0389 to APC 0266 with a 
median cost of $95.37 for CY 2007. Consistent with the statute, no 
Medicare beneficiary deductible will be applied to payment for this AAA 
screening service.

XIV. Emergency Medical Screening in Critical Access Hospitals (CAHs)

A. Background

    Section 1820 of the Act, as amended by section 4201 of the Balanced 
Budget Act of 1997, provides for the establishment of Medicare Rural 
Hospital Flexibility Programs (MRHFPs), under which individual States 
may designate certain facilities as critical access hospitals (CAHs). 
Facilities that are so designated and meet the CAH conditions of 
participations (CoPs) under 42 CFR Part 485, Subpart F, will be 
certified as CAHs by CMS. The MRHFP replaced the Essential Access 
Community Hospital (EACH)/Rural Primary Care Hospital (RPCH) program.

B. Proposed Policy Change

    Existing regulations governing CAHs at Sec.  485.618(d) require on-
call doctors and nonphysician practitioners who may be attending to 
urgent/acute medical problems in other areas of the CAH or outside the 
CAH to report to the CAH's emergency room within 30 minutes (60 minutes 
if the CAH is located in a frontier or remote area or permissible under 
the State's rural health care plan) to see a patient in the emergency 
room of a CAH. Often, these patients do not have emergency medical 
conditions. With changes to the regulations at Sec.  489.24 that 
implement the Emergency Medical Treatment and Labor Act (EMTALA) over 
the past few years, some practitioners have noted to CMS that the 
requirements regarding who should respond to calls to see patients who 
present to the emergency department of a CAH are more stringent than 
for general hospitals.
    The provider community recently requested that we change the 
emergency on-call personnel requirements for CAHs to conform to the 
regulatory changes published in the Federal Register on September 9, 
2003 (68 FR 53262). In response to this request, in the proposed rule 
published in the Federal Register on August 23, 2006 (71 FR 49623), we 
proposed to revise the current CAH CoPs to align the emergency medical 
screening requirements in CAHs with those applicable to acute care 
hospitals. We proposed to allow registered nurses, in addition to the 
personnel currently required at Sec.  485.618(d), to serve as qualified 
medical personnel to screen individuals who present to the CAH 
emergency room if the nature of the patient's request is within the 
registered nurse's scope of practice under State law and such screening 
is permitted by the CAH's bylaws. This proposed change would 
effectively eliminate the need for a doctor or nonphysician 
practitioner to report to the emergency department to attend to a 
nonemergent request for medical care if a registered nurse is on site 
at the CAH and has made a determination that the care needed is of a 
nonemergent nature.
    The EMTALA statute at section 1867 of the Act states that a 
hospital in this context must provide an appropriate (suitable for the 
symptoms presented) medical screening examination within the capability 
of the hospital's emergency department to determine whether or not an 
emergency medical condition exists (section 1866(a)(1)(I) of the Act 
imposes the section 1867 requirements on a CAH). The EMTALA regulations 
at Sec.  489.24(a) state that the examination must be conducted by 
qualified medical personnel. These qualified medical personnel 
designated to perform medical screening examinations must be determined 
qualified by the hospital's bylaws or rules and regulations and must be 
practicing within the scope of practice under State law.
    The regulations at Sec.  489.24(c) relating to the use of a 
dedicated emergency department for nonemergency services were added in 
September 2003 (68 FR 53262) to state that if an individual goes to a 
hospital's dedicated emergency department to request medical treatment, 
and the nature of the request makes it clear that the medical condition 
is not of an emergency nature, the hospital is required only to perform 
such screening as would be appropriate to determine that the individual 
does not have an emergency medical condition.
    Although EMTALA also applies to CAHs, the CoP for CAH emergency 
services (Sec.  485.618(d)) states that a physician, a physician 
assistant, a nurse practitioner, or a clinical nurse specialist, with 
training or experience in emergency care, must be on call and available 
onsite at a CAH within a specified timeframe. Therefore, under this CAH 
CoP, these are the only CAH personnel who are currently permitted to 
conduct an appropriate medical screening to determine that an 
individual, who presents in the manner described above, does not have 
an emergency medical condition (as required under Sec.  489.24(c)). In 
contrast, the emergency services CoP for acute care hospitals at Sec.  
482.55 does not specify the type of personnel who must be available to 
provide emergency services and who would, therefore, perform 
assessments and screenings. The regulation states only that the 
services must be organized and supervised under the direction of a 
qualified member of the medical staff and that there must be adequate 
medical and nursing personnel qualified in emergency care to meet the 
written emergency procedures and needs anticipated by the facility. 
Therefore, an acute care hospital may, if it chooses, have protocols 
that permit a registered nurse to conduct specific emergency medical 
screenings if the nature of the individual's request for examination 
and treatment is within the scope of practice of a registered nurse. 
For emergencies that are outside of a registered nurse's scope of 
practice, another qualified medical personnel (operating within his or 
her scope of practice under State law) would conduct the emergency 
medical screening.
    We proposed to revise the CAH standard at Sec.  485.618(d) to allow 
a CAH, if applicable, the flexibility of including a registered nurse, 
with training and experience in emergency care and who is on site at 
the CAH, as one of the qualified medical personnel available for 
emergency services, particularly emergency medical screenings, if the 
nature of the individual's request for medical care is within the 
registered nurse's scope of practice and is consistent with applicable 
State laws. If the registered nurse begins the emergency medical 
screening and determines that the nature of the individual's conditions 
is outside his or her scope of practice under State law, the physician, 
physician assistant, nurse practitioner or a clinical nurse specialist 
must be contacted to see the patient

[[Page 68160]]

within 30 or 60 minutes to conduct the emergency medical screening and 
provide stabilizing treatment. If the registered nurse knows initially 
that the medical screening for the presenting complaint is outside the 
applicable scope of practice under State law, the physician or other 
nonphysician practitioner must see the individual within the 30 or 60 
minute timeframes (as currently specified in Sec.  485.618(d)(1)).
    We recognize that not all CAHs will be able to utilize this 
flexibility. Some State licensure boards have stated that it is not 
within the authorized scope of practice for a registered nurse to 
independently perform an appropriate emergency medical screening for 
the purpose of determining if an emergency medical condition exists. 
However, the licensure boards in these States further maintain that it 
is within the scope of practice for a registered nurse to assess the 
health status of an individual to determine a nonemergent condition and 
to provide nursing care or to refer the individual to appropriate 
medical resources. Therefore, based on State law, some CAHs will not be 
able to designate registered nurses as qualified medical personnel 
under our proposed revision to the regulations governing CAHs. However, 
as we wished to provide flexibility to CAHs and to be consistent with 
existing EMTALA policy, we proposed the revision to the regulation at 
Sec.  485.618(d).

C. Public Comments Received on the Proposal

    We received 12 comments on our proposal. Our response follows each 
comment summary.
    Comment: All of the commenters supported the proposed revision of 
the current CoP to allow registered nurses with training and experience 
in emergency care to conduct specific medical screening examinations 
under certain provisions. Several of the commenters commended CMS for 
proposing a rule change that would afford CAHs the staffing flexibility 
needed to maintain access and to provide efficient emergency and urgent 
care services for their patients.
    Response: We appreciate the support of the provider community and 
believe that this revision to the current CoP will most likely decrease 
the regulatory burden for CAHs by allowing them greater staffing 
flexibility.
    Comment: Several commenters pointed out an inconsistency between 
the preamble language in the proposed rule, which notes that medical 
screening examinations by a registered nurse would be allowed only if 
such screenings were permitted by the CAH's bylaws, and the proposed 
regulation text, which does not mention the bylaws.
    Response: We appreciate the commenters bringing this inadvertent 
omission to our attention. We are revising the regulatory text at Sec.  
485.618(d)(2)(ii) in this final rule to indicate that the nature of a 
patient's request for medical care must be within the scope of practice 
and consistent with applicable State laws and the CAH's bylaws or rules 
and regulations in order for a registered nurse to conduct a medical 
screening examination. This revision to the language is also consistent 
with the EMTALA regulations at Sec.  489.24(a)(1)(i), which refer to 
hospital ``bylaws or rules and regulations.''
    Comment: One commenter questioned the impact that this change may 
have on payment and encouraged CMS to ensure that it does not adversely 
affect the payment that CAHs receive for screening services.
    Response: The change being made affects only the CAH CoPs and does 
not revise the CAH payment regulations, which are codifed at 42 CFR 
413.70.
    Comment: One commenter noted that, in the FY 2007 IPPS proposed 
rule for EMTALA false labor certifications, care roles and 
responsibilities were to be documented in the ``the medical staff 
bylaws or rules and regulations,'' while under the FY 2007 IPPS final 
rule, these roles and responsibilities are to be documented in 
``medical staff bylaws.'' The commenter requested a clarification on 
this issue due to concern that the final rule imposed a more 
restrictive requirement than was proposed by limiting documentation to 
the bylaws only.
    Response: The FY 2007 final IPPS rule is outside the scope of this 
rule and cannot be addressed here. We will address this comment in a 
future document.

D. Final Policy

    After consideration of the public comments received on the proposed 
rule, we are adopting the proposed change to Sec.  485.618(d), with 
minor modifications, to allow a CAH, if applicable, the flexibility of 
utilizing a registered nurse, with training and experience in emergency 
care, to conduct specific medical screening examinations only if the 
registered nurse is on site and immediately available at the CAH when a 
patient requests medical care and if the nature of the individual's 
request is within the registered nurse's scope of practice and 
consistent with applicable State laws and the CAH's bylaws or rules and 
regulations. As noted above, we have revised the regulatory text to 
include language regarding the CAH's bylaws, rules, and regulations. 
The revised regulatory text is now consistent with the preamble 
language contained in both the proposed rule and this final rule, and 
with the language in the EMTALA regulations at Sec.  489.24(a).

XV. OPPS Payment Status and Comment Indicators

A. CY 2007 Status Indicator Definitions

    The OPPS payment status indicators (SIs) that we assign to HCPCS 
codes and APCs play an important role in determining payment for 
services under the OPPS. They indicate whether a service represented by 
a HCPCS code is payable under the OPPS or another payment system and 
also whether particular OPPS policies apply to the code. Our CY 2007 
final status indicator assignments for APCs and HCPCS codes are shown 
in Addendum A and Addendum B, respectively. We are using the status 
indicators and definitions that are listed in Addendum D1, which we 
discuss below in greater detail.
1. Payment Status Indicators To Designate Services That Are Paid Under 
the OPPS
    The table of proposed status indicators in section XV. of the 
proposed rule (71 FR 49625) inadvertently listed radiopharmaceuticals 
under status indicator ``H'' rather than under status indicator ``K.'' 
Consistent with our CY 2007 proposed payment policy for 
radiopharmaceuticals (as discussed in section V.B.3.a.(3) of this 
preamble) and their associated status indicators as correctly listed in 
Addenda A and B of the CY 2007 proposed rule, the list of status 
indicators, the items, and their OPPS payment status descriptions are 
noted in the corrected table below.

[[Page 68161]]



         CY 2007 Proposed Payment Status Indicators (Corrected)
------------------------------------------------------------------------
          Indicator             Item/code/service    OPPS payment status
------------------------------------------------------------------------
G...........................  Pass-Through Drugs    Paid under OPPS;
                               and Biologicals.      Separate APC
                                                     payment includes
                                                     pass-through
                                                     amount.
H...........................  Pass-Through Device   Separate cost-based
                               Categories.           pass-through
                                                     payment; Not
                                                     subject to
                                                     coinsurance.
K...........................  (1) Non-Pass-Through  (1) Paid under OPPS;
                               Drugs, Biologicals,   Separate APC
                               and                   payment.
                               Radiopharmaceutical
                               Agents.
                              (2) Brachytherapy     (2) Paid under OPPS;
                               Sources.              Separate APC
                                                     payment.
                              (3) Blood and Blood   (3) Paid under OPPS;
                               Products.             Separate APC
                                                     payment.
N...........................  Items and Services    Paid under OPPS;
                               Packaged into APC     Payment is packaged
                               Rates.                into payment for
                                                     other services,
                                                     including outliers.
                                                     Therefore, there is
                                                     no separate APC
                                                     payment.
P...........................  Partial               Paid under OPPS; Per
                               Hospitalization.      diem APC payment.
Q...........................  Packaged Services     Paid under OPPS;
                               Subject to Separate   Addendum B displays
                               Payment Under OPPS    APC assignments
                               Payment Criteria.     when services are
                                                     separately payable.
                                                    (1) Separate APC
                                                     payment based on
                                                     OPPS payment
                                                     criteria.
                                                    (2) If criteria are
                                                     not met, payment is
                                                     packaged into
                                                     payment for other
                                                     services, including
                                                     outliers.
                                                     Therefore, there is
                                                     no separate APC
                                                     payment.
S...........................  Significant           Paid under OPPS;
                               Procedure, Not        Separate APC
                               Discounted when       payment.
                               Multiple.
T...........................  Significant           Paid under OPPS;
                               Procedure, Multiple   Separate APC
                               Reduction Applies.    payment.
V...........................  Clinic or Emergency   Paid under OPPS;
                               Department Visit.     Separate APC
                                                     payment.
X...........................  Ancillary Services..  Paid under OPPS;
                                                     Separate APC
                                                     payment.
------------------------------------------------------------------------

2. Payment Status Indicators To Designate Services That Are Paid Under 
a Payment System Other Than the OPPS

------------------------------------------------------------------------
          Indicator             Item/code/service    OPPS payment status
------------------------------------------------------------------------
A...........................  Services furnished    Not paid under OPPS.
                               to a hospital         Paid by fiscal
                               outpatient that are   intermediaries
                               paid under a fee      under a fee
                               schedule or payment   schedule or payment
                               system other than     system other than
                               OPPS, for example:    OPPS.
                               Ambulance
                               Services.
                               Clinical
                               Diagnostic
                               Laboratory Services.
                               Non-
                               Implantable
                               Prosthetic and
                               Orthotic Devices.
                               EPO for
                               ESRD Patients.
                               Physical,
                               Occupational, and
                               Speech Therapy.
                               Routine
                               Dialysis Services
                               for ESRD Patients
                               Provided in a
                               Certified Dialysis
                               Unit of a Hospital.
                               Diagnostic
                               Mammography.
                               Screening
                               Mammography.
C...........................  Inpatient Procedures  Not paid under OPPS.
                                                     Admit patient. Bill
                                                     as inpatient.
F...........................  Corneal Tissue        Not paid under OPPS.
                               Acquisition;          Paid at reasonable
                               Certain CRNA          cost.
                               Services; and
                               Hepatitis B
                               Vaccines.
L...........................  Influenza Vaccine;    Not paid under OPPS.
                               Pneumococcal          Paid at reasonable
                               Pneumonia Vaccine.    cost; Not subject
                                                     to deductible or
                                                     coinsurance.
M...........................  Items and Services    Not paid under OPPS.
                               Not Billable to the
                               Fiscal Intermediary.
Y...........................  Non-Implantable       Not paid under OPPS.
                               Durable Medical       All institutional
                               Equipment.            providers other
                                                     than home health
                                                     agencies bill to
                                                     DMERC.
------------------------------------------------------------------------

3. Payment Status Indicators To Designate Services That Are Not 
Recognized Under the OPPS But That May Be Recognized by Other 
Institutional Providers

[[Page 68162]]



------------------------------------------------------------------------
          Indicator             Item/code/service    OPPS payment status
------------------------------------------------------------------------
B...........................  Codes that are not    Not paid under OPPS.
                               recognized by OPPS    May be paid
                               when submitted on     by intermediaries
                               an outpatient         when submitted on a
                               hospital Part B       different bill
                               bill type (12x        type, for example,
                               and13x).              75x (CORF), but not
                                                     paid under OPPS.
                                                     An
                                                     alternate code that
                                                     is recognized by
                                                     OPPS when submitted
                                                     on an outpatient
                                                     hospital Part B
                                                     bill type (12x
                                                     and13x) may be
                                                     available.
------------------------------------------------------------------------

4. Payment Status Indicators To Designate Services That Are Not Payable 
by Medicare

------------------------------------------------------------------------
          Indicator             Item/code/service    OPPS payment status
------------------------------------------------------------------------
D...........................  Discontinued Codes..  Not paid under OPPS
                                                     or any other
                                                     Medicare payment
                                                     system.
E...........................  Items, Codes, and     Not paid under OPPS
                               Services:.            or any other
                               That are      Medicare payment
                               not covered by        system.
                               Medicare based on
                               statutory exclusion.
                               That are
                               not covered by
                               Medicare for
                               reasons other than
                               statutory exclusion.
                               That are
                               not recognized by
                               Medicare but for
                               which an alternate
                               code for the same
                               item or service may
                               be available.
                               For which
                               separate payment is
                               not provided by
                               Medicare.
------------------------------------------------------------------------

    We received several public comments regarding our general use of 
status indicators.
    Comment: Some commenters suggested that each status indicator 
definition should be ``pure'' and have only one meaning. Specifically, 
they recommended that the current OPPS status indicator ``B'' be split 
into two different status indicators, with descriptions that uniquely 
reflect the two situations in which ``B'' is currently assigned. In CY 
2006, the assignment of status indicator ``B,'' which identifies codes 
that are not recognized by the OPPS when submitted on an outpatient 
hospital Part B bill type (12X and 13X), reflects two possible reasons 
for its assignment to any specific HCPCS code: (1) Not paid under OPPS 
but may be paid by intermediaries when submitted on a different bill 
type, for example 75X (CORF); or (2) Not paid under OPPS but an 
alternate code that is recognized by OPPS when submitted on an 
outpatient hospital Part B bill type (12X and 13X) may be available. 
The commenters recommended that CMS continue to assign status indicator 
``B'' to codes not paid under the OPPS for the first reason and develop 
new status indicator ``Z'' for assignment to codes not recognized for 
the second reason.
    The commenters also recommended that CMS publish a separate 
addendum as part of the OPPS rule that lists the alternative HCPCS 
Level II codes for the OPPS that should be used for all codes that were 
assigned the suggested new status indicator ``Z.''
    Response: The OPPS has no operational need to split the definition 
of status indicator ``B'' and to establish a new status indicator ``Z'' 
as suggested by the commenters. As discussed previously, our status 
indicators exist for purposes of assisting in determining payment, and 
a single status indicator ``B'' is sufficient for both circumstances 
when codes may be paid by intermediaries when submitted on a different 
bill type but would not be paid under the OPPS or an alternate code 
might be recognized under the OPPS. In either situation, there is no 
payment effect that would require the differential use of two separate 
status indicators.
    There are currently 19 different status indicators in Addendum B 
that are used to indicate whether a service described by a HCPCS code 
is payable under the OPPS or another payment system and whether 
particular OPPS payment policies apply to the code. Two new status 
indicators, ``M'' and ``Q,'' were established in CY 2006 for purposes 
of identifying the OPPS payment status of certain HCPCS codes. We 
believe that only a limited number of status indicators in the OPPS are 
needed to convey the necessary payment-related information, and that 
additional indicators should only be created at this point when policy 
necessitates further refinements in this area. We also believe that 
with 19 status indicators for CY 2007, the set of indicators is 
appropriately specific, while maintaining the administrative simplicity 
associated with a modest number of status indicators.
    We are unable to develop and publish an addendum that lists the 
alternative codes that should be used for payment under the OPPS when a 
HCPCS code is not recognized under the OPPS because an alternate code 
may be available. Although the commenters suggested that alternative 
codes are Level II HCPCS codes, in some cases alternate codes are CPT 
codes that describe specific portions of a service. In other cases, 
there may be multiple alternative codes that could be used to report 
complete services or portions of services that were provided, and we 
have no way to determine in any given situation the specific services a 
hospital provided for which an alternative code or codes might be 
available. Therefore, we believe that it is appropriate for hospitals 
that provide a specific service to determine, in situations where they 
believe a HCPCS code with a status indicator of ``B'' would be their 
choice for reporting, whether that code could be reported on a 
different bill type and be paid, and, if not, determine if the service 
provided may be correctly reported with one or more other HCPCS codes 
that are recognized for payment under the OPPS. For some HCPCS codes 
not recognized under the OPPS, the determination of an appropriate 
alternate code or codes is straightforward, and we believe

[[Page 68163]]

hospitals have already developed such crosswalks for their own use 
based on the services they provide.
    Comment: One commenter stated that the community supported the CMS 
proposal to continue paying for the acquisition of corneal tissue as 
status indicator ``F'' as an item or service not paid under OPPS and 
paid at reasonable cost. The commenter believed that the adoption and 
implementation of an appropriate payment policy for the acquisition of 
corneal tissue for procedures provided in a hospital outpatient 
department setting was absolutely vital to the eye banking system, a 
network that was established for the single purpose of procuring and 
providing donated human eye tissue for sight restoring transplantation 
procedures.
    Response: We appreciate the commenter's support.
    We are finalizing our status indicator definitions to be consistent 
with the final CY 2007 OPPS payment policies. Because separately 
payable radiopharmaceuticals will continue to be paid on a cost-based 
methodology in CY 2007 as discussed in section V.B.3.a.(3) of this 
preamble, we will continue to assign them to status indicator ``H'' as 
indicated in the table set forth below and in Addendum D1 of this final 
rule with comment period, rather than to status indicator ``K'' as 
proposed. We also note we are finalizing our proposed description of 
status indicator ``K'' to include brachytherapy sources because, as 
discussed in section VII.B. of this final rule with comment period, 
these sources will be paid based on payment rates through brachytherapy 
source-specific APCs in CY 2007.

 CY 2007 Final Payment Status Indicators To Designate Services That Are
                           Paid Under the OPPS
------------------------------------------------------------------------
          Indicator             Item/code/service    OPPS payment status
------------------------------------------------------------------------
G...........................  Pass-Through Drugs    Paid under OPPS;
                               and Bio log icals.    Separate APC
                                                     payment includes
                                                     pass-through
                                                     amount.
H...........................  (1) Pass-Through      (1) Separate cost-
                               Device Categories.    based pass-through
                                                     payment; Not
                                                     subject to
                                                     coinsurance.
                              (2)Radiopharmaceutic  (2) Separate cost-
                               al Agents.            based non-pass-
                                                     through payment.
K...........................  (1) Non-Pass-Through  (1) Paid under OPPS;
                               Drugs and             Separate APC
                               Biologicals.          payment.
                              (2) Brachytherapy     (2) Paid under OPPS;
                               Sources.              Separate APC
                                                     payment.
                              (3) Blood and Blood   (3) Paid under OPPS;
                               Products.             Separate APC
                                                     payment.
N...........................  Items and Services    Paid under OPPS;
                               Packaged into APC     Payment is packaged
                               Rates.                into payment for
                                                     other services,
                                                     including outliers.
                                                     Therefore, there is
                                                     no separate APC
                                                     payment.
P...........................  Partial               Paid under OPPS; Per
                               Hospitalization.      diem APC payment.
Q...........................  Packaged Services     Paid under OPPS;
                               Subject to Separate   Addendum B displays
                               Payment Under OPPS    APC assignments
                               Payment Criteria.     when services are
                                                     separately payable.
                                                    (1) Separate APC
                                                     payment based on
                                                     OPPS payment
                                                     criteria.
                                                    (2) If criteria are
                                                     not met, payment is
                                                     packaged into
                                                     payment for other
                                                     services, including
                                                     outliers.
                                                     Therefore, there is
                                                     no separate APC
                                                     payment.
S...........................  Significant           Paid under OPPS;
                               Procedure, Not        Separate APC
                               Discounted when       payment.
                               Multiple.
T...........................  Significant           Paid under OPPS;
                               Procedure, Multiple   Separate APC
                               Reduction Applies.    payment.
V...........................  Clinic or Emergency   Paid under OPPS;
                               Department Visit.     Separate APC
                                                     payment.
X...........................  Ancillary Services..  Paid under OPPS;
                                                     Separate APC
                                                     payment.
------------------------------------------------------------------------

    To make the published Addendum B more relevant to the update of the 
OPPS, we are displaying in Addendum B of this final rule with comment 
period those HCPCS codes that describe items or services that are 
payable under the OPPS, as well as nonpayable codes for which we are 
making a final change in status for CY 2007. The final status 
indicators for items and services that are paid under the OPPS are 
listed in the table above.
    A complete listing of HCPCS codes with final OPPS payment status 
indicators and APC assignments for CY 2007 is available electronically 
on the CMS Web site http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage.

B. CY 2007 Comment Indicator Definitions

    In the November 15, 2004 final rule with comment period (69 FR 
65827 and 65828), we made final our policy to use two comment 
indicators to identify in an OPPS final rule the assignment status of a 
specific HCPCS code to an APC and the timeframe when comments on the 
HCPCS APC assignment would be accepted. These two comment indicators 
are listed below.
     ``NF''--New code, final APC assignment; comments were 
accepted on a proposed APC assignment in the proposed pule; APC 
assignment is no longer open to comment.
     ``NI''--New code, interim APC assignment; comments will be 
accepted on the interim APC assignment for the new code.
    In the November 10, 2005 final rule with comment period (70 FR 
68702 and 68703), we adopted a new comment indicator, with the final CY 
2007 definition as listed below:
     ``CH''--Active HCPCS code in current and next calendar 
year; status indicator and/or APC assignment has changed; or active 
HCPCS code that is discontinued at the end of the current calendar 
year.
    We implemented comment indicator ``CH'' to designate a change in 
payment status indicator and/or APC assignment for HCPCS codes in 
Addendum B of the CY 2006 final rule with comment period. We also 
stated that codes flagged with the ``CH'' indicator in that final rule 
would not be open to comment because the changes generally were 
previously subject to comment during the proposed rule comment period. 
As we proposed, we are continuing that policy in this CY 2007 OPPS 
final rule with comment period. When used in an OPPS final rule, the 
``CH'' indicator is only intended to facilitate the public's review of 
changes made from one calendar year to another. We are using the ``CH'' 
indicator in this CY 2007 final rule with comment period to indicate 
HCPCS codes for which the status indicator and/or APC assignment will 
change in CY 2007 and to indicate HCPCS codes that are discontinued at 
the end of the current calendar year. However, only HCPCS codes with

[[Page 68164]]

comment indicator ``NI'' in this CY 2007 OPPS final rule with comment 
period will be subject to comment during the comment period for this 
final rule with comment period.
    In the proposed rule, we used the ``CH'' indicator to call 
attention to changes in payment status indicators and/or APC 
assignments in the proposed rule to update the OPPS for CY 2007. We 
believed that using the ``CH'' indicator in the proposed rule 
facilitated the public's review of the changes that we proposed to make 
final in CY 2007. Use of the ``CH'' indicator in the proposed rule was 
significant because it highlighted changes that were subject to comment 
during the proposed rule comment period.
    The three comment indicators that we are implementing in CY 2007 
and their definitions are listed in Addendum D2 of this final rule with 
comment period.
    We received several public comments regarding the use of the 
proposed CY 2007 comment indicators.
    Comment: Several commenters recommended that the comment indicator 
``CH'' be limited to only a single change. Currently, ``CH'' is 
assigned to indicate one of two possible changes. It can signify that 
the HCPCS code has had a status indicator change, and it can also 
indicate that the HCPCS code has had an APC reassignment. The 
commenters argued that limiting ``CH'' to a single change would readily 
facilitate the identification of the HCPCS code changes and would 
minimize the need for visual comparison of two separate Addendum B 
files to determine what has actually changed.
    Response: The designation of HCPCS codes with comment indicator 
``CH'' is a new process that we initiated in the CY 2006 OPPS final 
rule to facilitate the public's review of changes that were proposed or 
finalized from one calendar year to another. We believe the specific 
reasoning behind the change is not necessary, as our intent is to 
merely flag the changes from our proposed rule to our final rule. We 
appreciate the comment and will consider possible refinements to 
comment indicators in the future that could assist the public in 
recognizing and identifying proposed and final changes to OPPS payment 
policies regarding specific items and services of interest.
    Comment: Several commenters asked CMS to clarify the use of status 
indicator ``NI'' and the length of time allowed for public comment 
regarding HCPCS codes with comment indicator ``NI.'' They also asked at 
exactly what point in time the ``NI'' designation would be removed.
    Response: Comment indicator ``NI'' flags HCPCS codes that are new 
for the CY 2007 OPPS final rule with comment period and that did not 
appear in the CY 2007 OPPS proposed rule. Codes with comment indicator 
``NI'' in Addendum B are open to comment in this CY 2007 final rule 
with comment period. The comment period for the OPPS final rule for a 
specific calendar year is specified as noted in the final rule. After 
the close of the final rule comment period, ``NI'' has no relevance, 
and it would not be applied to the same HCPCS codes for the next OPPS 
update year. The ``NI'' comment indicator is not used in the OPPS 
proposed rule because the status indicators and APC assignments of all 
HCPCS codes that appear in the proposed rule are open for public 
comment.
    After carefully considering the public comments received, we are 
implementing the comment indicators as proposed for CY 2007, with 
modification to the definition of comment indicator ``CH'' to include 
active HCPCS codes that are discontinued at the end of the current 
calendar year.

XVI. OPPS Policy and Payment Recommendations

A. MedPAC Recommendations

    The Medicare Payment Advisory Commission (MedPAC) submits reports 
to Congress in March and June that summarize payment policy 
recommendations. The March 2006 MedPAC report included the following 
recommendation relating specifically to the hospital OPPS:
    Recommendation 2A: The Congress should increase payment rates for 
the acute inpatient and outpatient prospective payment systems in 2007 
by the projected increase in the hospital market basket index less half 
of the Commission's expectation for productivity growth. A discussion 
of the MedPAC recommendation regarding updates to the market basket was 
included in section II.C. (``OPPS Conversion Factor Update for 2007'') 
of the proposed rule (71 FR 49539).
    There have been no subsequent MedPAC recommendations with regard to 
Medicare payment under the OPPS.

B. APC Panel Recommendations

    Recommendations made by the APC Panel at its March and August 2006 
meetings are discussed in sections of this preamble that correspond to 
topics addressed by the APC Panel. Minutes of the APC Panel's March 1-
2, 2006 meeting are available online at: http://www.cms.hhs.gov/FACA/05_AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp.
    The APC Panel met on August 23-24, 2006 to discuss the CY 2007 OPPS 
proposed rule and to hear testimony from concerned members of the 
public. The minutes of the meeting are available at: http://
www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassification[fxsp
0]Groups.asp#TopOfPage.

C. GAO Recommendations

    A discussion of the October 31, 2005 GAO letter of comment on 
proposed 2006 specified covered outpatient drug (SCOD) rates (GAO-06-
17R ``Comments on Proposed 2006 SCOD Rates'') was contained in section 
V.3.B.a. of the CY 2007 OPPS proposed rule (71 FR 49584). The letter is 
referenced in section V.B. of this final rule with comment.
    A discussion of the April 2006 GAO report entitled ``Medicare 
Hospital Pharmaceuticals: Survey Shows Price Variation and Highlights 
Data Collection Lessons and Outpatient Rate-setting Challenges for 
CMS'' (GAO-06-372) was contained in section V.3.B.a. of the CY 2007 
OPPS proposed rule (71 FR 49584). The report is referenced in section 
V.B. of this final rule with comment period.
    A discussion of the July 26, 2006 GAO report entitled ``Medicare 
Outpatient Payments: Rates for Certain Radioactive Sources Used in 
Brachytherapy Could be Set Prospectively'' (GAO 06-635) is contained in 
section VII.B. of this final rule with comment period.
    These GAO reports are available for review in their entirety at: 
http://www.GAO.gov.

XVII. Policies Affecting Ambulatory Surgical Centers (ASCs) for CY 2007

A. ASC Background

1. Legislative History
    Section 1832(a)(2)(F)(i) of the Act provides that benefits under 
the Medicare Supplementary Medical Insurance program (Part B) include 
payment for facility services furnished in connection with surgical 
procedures the Secretary specifies that are performed in an ambulatory 
surgical center (ASC). To participate in the Medicare program as an 
ASC, a facility must meet the standards specified in section 
1832(a)(2)(F)(i) of the Act; in 42 CFR 416, subpart B of our 
regulations, which sets forth general conditions and requirements for 
ASCs; and in 42 CFR 416, subpart C of our regulations, which provides 
specific conditions for coverage for ASCs.

[[Page 68165]]

    The ASC services benefit was enacted by Congress through the 
Omnibus Reconciliation Act of 1980 (Pub. L. 96-499). For a detailed 
discussion of the legislative history related to ASCs, we refer readers 
to the June 12, 1998 proposed rule (63 FR 32291).
    Section 626(b) of Public Law 108-173 repealed the requirement 
formerly found in section 1833(i)(2)(A) of the Act that the Secretary 
conduct a survey of ASC costs for purposes of updating ASC payment 
rates and, instead, requires the Secretary to implement a revised ASC 
payment system, to be effective not later than January 1, 2008. In 
section XVIII. of the CY 2007 OPPS proposed rule (71 FR 49635), we set 
forth our proposal for a revised ASC payment system that would be 
implemented on January 1, 2008. We are in the process of receiving and 
analyzing public comments on this proposal and we expect to issue a 
separate final rule for the revised ASC payment system sometime in the 
spring of 2007 to be effective January 1, 2008.
    Section 5103 of Public Law 109-171 amended section 1833(i)(2) of 
the Act by adding a new subparagraph (E) to place a limitation on 
payments for surgical procedures in ASCs. If the standard overhead 
amount under section 1833(i)(2)(A) of the Act for a facility service 
for such procedure, without application of any geographic adjustment 
exceeds the Medicare OPPS payment amount for the service for that year, 
without application of any geographic adjustment, the Secretary shall 
substitute the OPPS payment amount for the ASC standard overhead 
amount. This provision applies to surgical procedures furnished in ASCs 
on or after January 1, 2007, and before the effective date of the 
revised ASC payment system.
    We discuss in section XVII.B. of this preamble additions to and 
deletions from the list of Medicare-approved ASC procedures to be 
implemented January 1, 2007, prior to implementation of the revised ASC 
payment system. In section XVII.C. of this preamble, we discuss the 
regulatory changes that we are making for our current ASC payment 
system. In section XVII.D. of this preamble, we address the provisions 
of sections 1834(d)(2) and (d)(3) of the Act regarding payment amounts 
and beneficiary coinsurance amounts for screening flexible 
sigmoidoscopy and screening colonoscopy. In section XVII.E. of this 
preamble, we address the changes in payment to ASCs mandated by section 
5103 of Public Law 109-171. In addition, in section XVII.F. of this 
preamble, we are making changes in the process to review payment 
adjustments for insertion of new technology intraocular lenses 
(NTIOLs). In section XVII.G. of this preamble, we announce the CY 2007 
deadline for submitting requests for CMS review of appropriateness of 
ASC payment for insertion following cataract surgery of an NTIOL.
    In section XVIII. of the preamble of the CY 2007 OPPS proposed rule 
(71 FR 49635), we proposed a revised payment system for ASCs to be 
implemented effective January 1, 2008, including revisions to the ASC 
list for CY 2008, the ratesetting method, and the applicable ASC 
regulations to incorporate the requirements and payments for ASC 
facility services under the proposed revised ASC system. We will be 
addressing the public comments received and implementing the revised 
ASC payment system in a separate final rule that we expect to be 
published separately in 2007.
2. Current Payment Method
    There are two primary elements in the total cost of performing a 
surgical procedure: (a) The cost of the physician's professional 
services to perform the procedure; and (b) the cost of items and 
services furnished by the facility where the procedure is performed 
(for example, surgical supplies, equipment, and nursing services). 
Payment for the first element is made under the MPFS. In the proposed 
rule and in this final rule with comment period, we address the second 
element, the payment of facility fees for ASC services. We also address 
the coverage of ASC services in the proposed rule and in this final 
rule with comment period.
    Under the current ASC facility services payment system, the ASC 
payment rate is a standard overhead amount established on the basis of 
our estimate of a fee that takes into account the costs incurred by 
ASCs generally in providing facility services in connection with 
performing a specific procedure. The report of the Conference Committee 
accompanying section 934 of the Omnibus Reconciliation Act of 1980 
(ORA), Public Law 96-499, which enacted the ASC benefit in December 
1980, states that this overhead amount is expected to be calculated on 
a prospective basis using sample survey data and similar techniques to 
establish reasonable estimated overhead allowances, which take into 
account volume (within reasonable limits), for each of the listed 
procedures. (H.R. Rep. No. 96-1479, at 134-35 (1980).)
    To establish those reasonable estimated allowances for services 
furnished prior to implementation of the revised ASC payment system, 
section 626(b)(1) of Public Law 108-173 amended section 
1833(i)(2)(A)(i) of the Act to require us to take into account the 
audited costs incurred by ASCs to perform a procedure, in accordance 
with a survey. Except for screening flexible sigmoidoscopy and 
screening colonoscopy services, payment for ASC facility services is 
subject to the usual Medicare Part B deductible and coinsurance 
requirements and the amounts paid by Medicare must be 80 percent of the 
standard fee.
    Section 1833(i)(1) of the Act requires us to specify, in 
consultation with appropriate medical organizations, surgical 
procedures that are appropriately performed on an inpatient basis in a 
hospital but that can be safely performed in an ASC and to review and 
update the list of ASC procedures at least every 2 years.
    Section 141(b) of the Social Security Act Amendments of 1994, 
Public Law 103-432, requires us to establish a process for reviewing 
the appropriateness of the payment amount provided under section 
1833(i)(2)(A)(iii) of the Act for intraocular lenses (IOLs) for a class 
of new technology IOLs (NTIOLs). That process was the subject of a 
separate final rule entitled ``Adjustment in Payment Amounts for New 
Technology Intraocular Lenses Furnished by Ambulatory Surgical 
Centers,'' published in the June 16, 1999 Federal Register (64 FR 
32198). As stated earlier, in section XVII.E. of the preamble of this 
final rule with comment period, we discuss the changes that we are 
making to that process.
    A summary of changes to ASC payment rates made prior to CY 1998 may 
be found in the June 12, 1998 proposed rule (63 FR 32292). The 1998 
rule proposed to rebase the ASC payment rates using cost, charge, and 
utilization data collected by a 1994 survey of ASCs. In that proposed 
rule, we also proposed to refine the ratesetting methodology that was 
implemented in the February 8, 1990 Federal Register (55 FR 4577). 
However, the changes that were proposed for the ratesetting methodology 
were not implemented because of a combination of circumstances 
resulting in the delayed publication of a final rule. Those 
circumstances included several extensions to the comment period which 
ended July 30, 1999, Year 2000 (Y2K) Medicare systems compliancy 
considerations, and legislative changes required by the Medicare, 
Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), 
Public Law 106-113, and the Medicare, Medicaid, and SCHIP Benefits 
Improvement and

[[Page 68166]]

Protection Act of 2000 (BIPA), Public Law 106-554. Readers may refer to 
the March 28, 2003 ASC List Update final rule (68 FR 15268-69) for a 
detailed discussion of these circumstances and the legislative changes.
3. Published Changes to the ASC List
    Section 1833(i)(1)(A) of the Act requires the Secretary to specify 
surgical procedures that, although appropriately performed in an 
inpatient hospital setting, can also be performed safely on an 
ambulatory basis in an ASC, a CAH, or a hospital outpatient department. 
The report accompanying the legislation explained that the Congress 
intended procedures currently performed on an ambulatory basis in a 
physician's office that do not generally require the more elaborate 
facilities of an ASC not be included in the list of ASC covered 
procedures (H.R. Rep. No. 96-1167, at 390-91, reprinted in 1980 
U.S.C.C.A.N. 5526, 5753-54). In a final rule published August 5, 1982, 
in the Federal Register (47 FR 34082), we established regulations that 
included criteria for specifying which surgical procedures were to be 
included for purposes of implementing the ASC facility benefit.
    Section 416.65(a) of the regulations specifies general standards 
for procedures on the ASC list. ASC procedures are those surgical and 
other medial procedures that are--
     Commonly performed on an inpatient basis but may be safely 
performed in an ASC;
     Not of a type that are commonly performed or that may be 
safely performed in physicians offices;
     Limited to procedures requiring a dedicated operating room 
or suite and generally requiring a post-operative recovery room or 
short-term (not overnight) convalescent room; and
     Not otherwise excluded from Medicare coverage.
    Specific standards in Sec.  416.65(b) limit covered ASC procedures 
to those that do not generally exceed 90 minutes operating time and a 
total of 4 hours recovery or convalescent time. If anesthesia is 
required, the anesthesia must be local or regional anesthesia, or 
general anesthesia of not more than 90 minutes duration.
    Section 416.65(b)(3) of the regulations excludes from the ASC list 
procedures that generally result in extensive blood loss, that require 
major or prolonged invasion of body cavities, that directly involve 
major blood vessels, or that are generally emergency or life-
threatening in nature.
    A detailed history of published changes to the ASC list and ASC 
payment rates may be found in the June 12, 1998 proposed rule (63 FR 
32292). Subsequently, in accordance with Sec.  416.65(c), we published 
updates of the ASC list in the Federal Register on March 28, 2003 (68 
FR 15268) and May 4, 2005 (70 FR 23690).
    During years when we have not updated the ASC list in the Federal 
Register, we have revised the list to be consistent with annual 
calendar year changes to HCPCS and CPT codes. These annual coding 
updates have been implemented through program instructions to the 
carriers that process ASC claims. The most recent update to the list to 
conform to CPT and HCPCS coding changes was published in Transmittal R-
720-CP, Change Request 4082, on October 21, 2005. The transmittal may 
be found on our Web site at: http://www.cms.hhs.gov/Transmittals/.

B. ASC List Update Effective for Services Furnished On or After January 
1, 2007

1. Criteria for Additions to or Deletions From the ASC List
    In April 1987, we adopted quantitative criteria for identifying 
procedures that were commonly performed either in a hospital inpatient 
setting or in a physician's office. Collectively, commenters responding 
to a notice published on February 16, 1984, in the Federal Register (49 
FR 6023) had recommended that virtually every surgical CPT code be 
included on the ASC list. Our medical staff reviewed the recommended 
additions to the list, in consultation with other specialist physicians 
and medical organizations, as appropriate, to determine which code or 
series of codes were appropriately performed on an ambulatory basis 
within the framework of the regulatory criteria in Sec.  416.65. 
However, when we arrayed the proposed procedures by the site where they 
were most frequently performed according to our claims payment data 
files (1984 Part B Medicare Data (BMAD)), we found that many procedures 
were not commonly performed on an inpatient basis or were performed in 
a physician's office the majority of the time, and, thus, would not 
meet the standards in our regulations. Therefore, we decided that if a 
procedure was performed on an inpatient basis 20 percent of the time or 
less, or in a physician's office 50 percent of the time or more, it 
would be excluded from the ASC list. (April 21, 1987 (52 FR 13176)).
    At the time, we believed that these utilization thresholds best 
reflected the legislative objectives of moving procedures from the more 
expensive hospital inpatient setting to the less expensive ASC setting 
without encouraging the migration of procedures from the generally less 
expensive physician's office setting to the ASC. We applied these 
quantitative standards not only to codes proposed for addition to the 
ASC list, but also to the codes that were currently on the list, to 
delete codes that did not meet the thresholds.
    The trend towards performing surgery on an ambulatory or outpatient 
basis grew steadily and, by 1995, we discovered that a number of 
procedures that were on the ASC list at the time fell short of the 20 
percent and 50 percent thresholds, even though the procedures were 
obviously appropriate in the ASC setting. The most notable of these was 
cataract extraction with intraocular lens insertion that were already 
being performed predominately in outpatient settings by the early 
1990s, although more than 20 percent were also performed as inpatient 
procedures. The thresholds would also have excluded from the ASC list 
certain newer procedures, such as CPT code 66825 (Repositioning of 
intraocular lens prosthesis, requiring an incision (separate 
procedure)), that were rarely performed on a hospital inpatient basis 
but that were appropriate for the ASC setting. Strict adherence to the 
same 20 percent and 50 percent thresholds both to add and remove 
procedures did not provide latitude for minor fluctuations in 
utilization across settings or errors that could occur in the site-of-
service data drawn from the National Claims History File that we were 
then using for analysis.
    In an effort to avoid these anomalies but still retain a relatively 
objective standard for determining which procedures should comprise the 
ASC list, we adopted in the Federal Register notice with comment period 
published on January 26, 1995 (60 FR 5185), a modified standard for 
deleting procedures already on the list. We deleted from the list only 
those procedures whose combined hospital inpatient, hospital 
outpatient, and ASC site-of-service volume was less than 46 percent of 
the procedure's total volume and that were either performed 50 percent 
of the time or more in the physician's office or 10 percent of the time 
or less in an inpatient hospital setting. We retained the 20 percent 
and 50 percent standard to determine which procedures would be 
appropriate additions to the ASC list.
    In the CY 2007 OPPS proposed rule, we did not propose changes to 
the criteria for adding or deleting items from the ASC list effective 
January 1, 2007. However, in section XVIII.B. of the proposed rule, we 
did discuss

[[Page 68167]]

proposed changes in the context of developing a revised ASC payment 
system to be effective January 1, 2008. The proposed changes to the 
criteria would result in the addition for CY 2008 of many procedures 
that do not meet the current criteria for addition to the list. As we 
indicated earlier, we expect the final rule that will implement the 
revised ASC payment system effective January 1, 2008 to be published as 
a separate document in the spring of 2007.
2. Rationale for Payment Assignment
    Currently, procedures on the ASC list are assigned to one of nine 
payment groups based on our estimate of the costs incurred by the 
facility to perform the procedure. In the CY 2007 OPPS proposed rule, 
we did not propose any changes to those nine payment groups; and we 
proposed to assign the procedures to be added to the ASC list to one of 
those existing payment groups. The payment group to which we assign 
each addition to the ASC list is judged by our medical advisors to be 
most appropriate in terms of facility resource inputs. The list of 
procedures eligible for Medicare payment of a facility fee and the 
rates for CY 2007 are displayed in Addendum AA of this final rule with 
comment period. The procedures that are affected by the payment limit 
required by section 5103 of Public Law 109-171 are identified in that 
addendum along with their payment rates.
3. Response to Comments to May 4, 2005 Interim Final Rule for the ASC 
Update
    In accordance with section 1833(i)(1) of the Act, as we proposed in 
the CY 2007 OPPS proposed rule, we are updating the list of procedures 
that are covered when furnished in an ASC, effective January 1, 2007. 
In the process of determining which procedures to add to the list, we 
focused on requests we received from the public in their comments on 
our May 4, 2005 interim final rule (70 FR 23690). We evaluated codes 
for which we received requests from the public. The public comments 
include requests for addition and deletion of specific procedures and 
for assignment to higher payment groups for specific procedures.
4. Procedures Proposed for Additions to the ASC List
    Using the current criteria as described in section XVII.B.1. of 
this preamble, we identified 14 procedures to propose for addition to 
the ASC list effective January 1, 2007. The procedures were assigned to 
one of the nine existing ASC payment groups as indicated in Table 41 of 
the 2007 OPPS proposed rule (71 FR 49629), set out below as Table 47-A.

 Table 47-A.--Procedures Proposed for Addition to the ASC List Effective
                             January 1, 2007
------------------------------------------------------------------------
                                                           ASC payment
           CPT                   Short descriptor             group
------------------------------------------------------------------------
13102...................  Repair wound/lesion add-on...               1
13122...................  Repair wound/lesion add-on...               1
13133...................  Repair wound/lesion add-on...               1
19297...................  Place breast cath for rad....               9
21356...................  Treat cheek bone fracture....               3
22520...................  Percutaneous vertebroplasty,                9
                           thor.
22521...................  Percutaneous vertebroplasty,                9
                           lumb.
22522...................  Percutaneous vertebroplasty,                1
                           add'l.
35476...................  Repair venous blockage.......               9
36818...................  AV fuse, upper arm, cephalic.               3
37205...................  Transcath IV stent,                         9
                           percutaneous.
37206...................  Transcath IV stent/perc,                    1
                           add'l.
43761...................  Reposition gastrostomy tube..               1
46946...................  Ligation of hemorrhoids......               1
------------------------------------------------------------------------

    We received many comments in support of our proposal to add the 
procedures displayed in Table 47-A. In addition, some commenters 
requested that we add other procedures, that we assign specific 
procedures to higher payment groups, and that we not add several of the 
proposed procedures to the list.
5. Specific Requests for Payment Group Changes to the Proposed ASC List 
of Additions
    Comment: One commenter supported the proposal to add CPT code 21356 
(Open treatment of depressed zygomatic arch fracture (eg, Gillies 
approach)) but requested that CMS assign the procedure to payment group 
9 rather than group 3, as proposed. The commenter stated that the ASC 
costs for the procedure are $1,365, and that the group 3 payment of 
$510 would not nearly cover those costs.
    Response: We assigned the procedure to the same payment groups as 
CPT code 21355 (Percutaneous treatment of fracture of malar area, 
including zygomatic arch and malar tripod, with manipulation) because 
we believe that facility costs are similar for the two procedures. We 
re-examined the facility resource requirements and clinical 
characteristics of CPT code 21356 and remain convinced that our 
proposed assignment of CPT code 21356 to payment group 3 is 
appropriate. Therefore, we are finalizing the assignment for this 
procedure in payment group 3, as proposed.
    Comment: A few commenters supported the proposed addition of CPT 
codes 22520 (Percutaneous vertebroplasty, one vertebral body, 
unilateral or bilateral injection; thoracic); 22521 (Percutaneous 
vertebroplasty, one vertebral body, unilateral or bilateral injection; 
lumbar); and 22522 (Percutaneous vertebroplasty, one vertebral body, 
unilateral or bilateral injection; each additional thoracic or lumbar 
vertebral body) to the ASC list for CY 2007. The commenters requested 
that CMS assign CPT code 22522 to payment group 9 as CMS did CPT codes 
22520 and 22521. They stated that, although CPT code 22522 represents 
an add-on procedure, it nonetheless requires a kit that costs in the 
range of $700 to $1,400. They stated that the facility payment for the 
procedure is always subject to the multiple procedure discount because 
it is an add-on procedure, and even the full group 1 payment would not 
cover those costs.
    Response: We agree with the commenters' assertion that when 
additional kit(s) are required for performing CPT code 22522, those 
extra costs would not be adequately recognized by payment at the group 
1 level, especially because the procedure can only be billed 
secondarily to another procedure, and payment will always be discounted 
by half due to multiple procedure discounting. For these reasons, we 
believe that CPT code 22522 would be more appropriately assigned to 
payment group 9 than to group 1 as we proposed. We are finalizing the 
assignment of CPT code 22522 to ASC payment group 9 for CY 2007.
    Comment: Some commenters supported the proposal to add CPT code 
36818 (Arteriovenous anastomosis, open; by upper arm cephalic vein 
transposition) to the ASC list for CY 2007 and requested that CMS 
assign the procedure to a higher ASC payment group than group 3 as we 
proposed.
    Response: We proposed to assign the procedure to group 3 because 
that is the payment level for CPT code 36819 (Arteriovenous 
anastomosis, open; by upper arm basilica vein transposition). The 
commenter provided no evidence to

[[Page 68168]]

support assignment to a higher payment group, and we found nothing in 
our data to suggest that payment for CPT code 36818 should be higher 
than what we proposed. We believe that assignment to the same level as 
CPT code 36819 is appropriate and that payment at the group 3 level 
appropriately recognizes facility costs for the procedure. Therefore, 
we are finalizing our assignment of CPT code 36818 to ASC payment group 
3 as proposed.
    Comment: Many commenters supported the proposal to add CPT codes 
37205 (Transcatheter placement of an intravascular stent(s), (except 
coronary, carotid, and vertebral vessel), percutaneous; initial vessel) 
and 37206 (Transcatheter placement of an intravascular stent(s), 
(except coronary, carotid, and vertebral vessel), percutaneous; each 
additional vessel) to the ASC list. However, a number of commenters 
requested that CMS not add these CPT codes to the ASC list. These 
commenters stated that the procedures do not satisfy the criteria for 
inclusion on the ASC list because they involve major blood vessels, 
would exceed the 90-minute limit on operating room time, and may be 
associated with complications that are threatening to patient safety.
    Response: We found the divergence of responses among the public 
comments troubling and reexamined our proposal to add these procedures 
to the ASC list. Although the procedures are being performed about half 
of the time in hospital outpatient departments (HOPDs), the other half 
are being performed on an inpatient basis and they virtually are never 
done in a physician office. As we have stated in the past, there are 
many procedures that may be safely performed in a hospital outpatient 
department that may not be safely provided in an ASC, because only the 
hospital outpatient department has immediate access to the full 
spectrum of emergency and acute care facilities of the hospital.
    Our medical advisors reconsidered our proposal to add CPT codes 
37205 and 37206 to the ASC list and determined that it would be in the 
best interests of Medicare beneficiaries to continue to deny payment 
for them in ASC facilities. Our medical advisors believe that the 
procedures would require more than 4 hours of recovery time and would 
most often require an overnight stay in the facility.
    For these reasons, we are not finalizing our proposal to add CPT 
codes 37205 and 37206 to the ASC list for CY 2007.
    Comment: Many commenters supported the proposed addition of CPT 
code 35476 (Transluminal balloon angioplasty, percutaneous; venous) to 
the ASC list for CY 2007. In general, the commenters stated that 
providing access to the procedure in ASCs would be a great benefit to 
dialysis patients who are often in need of angioplasty procedures. One 
commenter objected to its addition to the list on the grounds that it 
was a significant safety risk because the procedures described by CPT 
code 35476 may involve large veins, with the potential for serious 
complications that should be handled in the hospital setting.
    Some commenters were disappointed that CMS did not also propose to 
add CPT code 35475 (Transluminal balloon angioplasty, percutaneous; 
brachiocephalic trunk or branches, each vessel). They stressed the 
importance of our support of the Fistula First ESRD quality initiative 
and stated that including CPT code 35475 would provide patients with a 
more efficient, but equally effective, option for ensuring the 
maintenance of their AV fistulas for vascular access. They also stated 
that inclusion of both CPT codes 35475 and 35476 on the ASC list would 
save lives, as well as reduce Medicare expenditures because rates of 
patient complications and hospitalizations would be decreased.
    Response: We are sympathetic to the commenters' request for the 
arterial code, CPT 35475, to be added to the ASC list. We did not 
propose to add CPT code 35475 because use of the code is not limited to 
procedures involving arteries in the anatomic sites used for vascular 
access for hemodialysis or to procedures normally performed to maintain 
arteriovenous (AV) fistulas. Procedures involving more proximal major 
arteries, and therefore that present safety concerns for performance in 
ASCs, are also reported by CPT code 35475, and so the code does not 
meet the clinical criteria for inclusion on the ASC list.
    Additionally, on further review, we also believe it is most 
clinically appropriate to not finalize our proposal to add CPT code 
35476 to the ASC list. Although CPT code 35476 is used to report venous 
rather than arterial procedures, it is appropriately used to report 
many different procedures, some of which may involve major veins and 
that are potentially too unsafe for performance in ASCs.
    However, we are committed to the Fistula First end-stage renal 
disease quality initiative and want to improve access to needed 
procedural services for dialysis patients if at all possible. We 
believe that in order to maintain healthy vascular access sites for 
dialysis patients, physicians may need to perform both venous and 
arterial angioplasty procedures concurrently. As discussed above, we 
will not be adding CPT code 35475 for arterial angioplasties to the ASC 
list, and we are not finalizing our proposal to add CPT code 35476 for 
venous angioplasties to the ASC list because of safety concerns due to 
the broad array of vessel angioplasties that could be reported with the 
two codes. Instead, in order to make those angioplasty procedures for 
AV fistula maintenance, which could otherwise be appropriately reported 
with CPT codes 35475 and 35476, available for Medicare payment in ASCs, 
we are implementing two new HCPCS G-codes to specifically describe the 
arterial and venous angioplasty procedures to maintain hemodialysis 
access through arteriovenous fistula or grafts for dialysis patients. 
These codes are G0392 (Transluminal balloon angioplasty, percutaneous; 
hemodialysis access fistula or graft; arterial) and G0393 (Transluminal 
balloon angioplasty, percutaneous; hemodialysis access fistula or 
graft; venous). We are adding both HCPCS codes G0392 and G0393 to the 
ASC list for CY 2007 and are assigning them to ASC payment group 9.
    Table 47-B displays final decisions regarding the procedures we 
proposed to add to the ASC list for CY 2007.

Table 47-B.--Final Additions from the Proposed Additions to the ASC List
                        Effective January 1, 2007
------------------------------------------------------------------------
                                                                   ASC
                 CPT                       Short descriptor      payment
                                                                  group
------------------------------------------------------------------------
13102................................  Repair wound/lesion add-        1
                                        on.
13122................................  Repair wound/lesion add-        1
                                        on.
13133................................  Repair wound/lesion add-        1
                                        on.
19297................................  Place breast cath for           9
                                        rad.
21356................................  Treat cheek bone                3
                                        fracture.
22520................................  Percutaneous                    9
                                        vertebroplasty, thor.
22521................................  Percutaneous                    9
                                        vertebroplasty, lumb.
22522................................  Percutaneous                    9
                                        vertebroplasty, add'l.
36818................................  AV fuse, upper arm,             3
                                        cephalic.
43761................................  Reposition gastrostomy          1
                                        tube.
46946................................  Ligation of hemorrhoids         1
------------------------------------------------------------------------


[[Page 68169]]

    The G-codes and other additions to the list that are being made in 
response to comments on the proposed rule are displayed in Table 48, 
Additional Procedures for Addition to the ASC List for CY 2007.
6. Requests for Additions to the ASC List from Comments to the August 
23, 2006 Proposed Rule
a. Requests Accepted for Additions to the ASC List for CY 2007
    Comment: Many comments requested that CMS add CPT code 13153 
(Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm 
or less) to the ASC list for CY 2007. The commenters supported our 
proposal to add CPT codes 13102 (Repair, complex, trunk; 1.1 cm to 2.5 
cm); 13122 (Repair, complex, trunk; 2.6 cm to 7.5 cm); and 13133 
(Repair, complex, trunk; each additional 5 cm or less) to the list, but 
stated that CMS also should have proposed to add CPT code 13153, which 
is the only code in this series of CPT codes that was not proposed to 
be added. They stated that CPT code 13153 is comparable to the other 
codes already on the list and should be assigned to group 3 with the 
other codes in its series, CPT codes 13150 (Repair, complex, eyelids, 
nose, ears and/or lips; 1.0 cm or less), 13151 (Repair, complex, 
eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm) and 13152 (Repair, 
complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm).
    Response: We agree with the commenters. We examined the series of 
codes and found that CPT code 13153 is the only one not proposed to be 
on the CY 2007 list. The base code to which CPT code 13153 is an add-on 
code is 13150 (Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm 
or less) and is assigned to payment group 3. We agree that it is 
appropriate to assign CPT code 13153 to the same payment group as CPT 
code 13150 because the procedure can only be billed secondarily to 
another procedure, so payment will always be discounted by half due to 
multiple procedure discounting. Therefore, we are adding CPT code 13153 
to the ASC list in group 3 for CY 2007.
    Comment: Several commenters requested that CMS add CPT code 19295 
(Image guided placement, metallic localization clip, percutaneous, 
during breast biopsy) to the ASC list. The commenters stated that this 
add-on procedure is performed in conjunction with breast biopsies that 
are on the ASC list. They stated that it is appropriate to allow 
payment for this service as well.
    Response: We agree with the commenters that the addition of CPT 
code 19295 to the list is appropriate for CY 2007. We are adding it to 
the list and assigning it to ASC payment group 1. We believe this 
procedure is important to providing high quality health care for women 
undergoing evaluation for possible breast cancer, often as a result of 
the findings from screening mammography.
    Comment: One commenter requested the addition of CPT code 31620 
(Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or 
therapeutic intervention(s)) to the ASC list. The commenters explained 
that it is an add-on procedure that is performed in conjunction with 
bronchoscopies that are on the ASC list, and the procedure meets all of 
the criteria for inclusion on the list for CY 2007.
    Response: We agree with the commenter that CPT code 31620 is an 
appropriate procedure for payment in the ASC and are adding it to the 
ASC list for CY 2007 in group 1, where CPT code 31622 (Bronchoscopy, 
rigid or flexible, with or without fluoroscopic guidance; diagnostic, 
with or without cell washing) and other procedures with similar 
resource requirements are assigned.
    Comment: Several commenters requested that CMS add CPT code 43257 
(Upper gastrointestinal endoscopy including esophagus, stomach, and 
either the duodenum and/or jejunum as appropriate; with delivery of 
thermal energy to the muscle of lower esophageal sphincter and/or 
gastric cardia, for treatment of gastroesophageal reflux disease) to 
the ASC list for CY 2007. The commenters stated that they believed that 
this treatment for gastroesophageal reflux disease met all the current 
clinical criteria for inclusion on the ASC list.
    Response: We agree with the commenters that this procedure 
satisfies our clinical criteria for addition to the list. The 
utilization data indicate that the procedure is performed 95 percent of 
the time in the hospital outpatient department. Based on the 
utilization data that indicate the safety of performing the procedure 
in outpatient settings in addition to our medical advisors' clinical 
judgment that it is an appropriate procedure for performance in the 
ASC, we are adding CPT code 43257 to the list for CY 2007 and assigning 
it to payment group 3.
    Comment: Several commenters requested that CMS add CPT code 57267 
(Insertion of mesh or other prosthesis for repair of pelvic floor 
defect, each site (anterior, posterior compartment), vaginal approach) 
to the ASC list for CY 2007 and assign it to payment group 7. The 
commenters stated that the procedure costs were very similar to those 
for CPT code 49568 (Implantation of mesh or other prosthesis for 
incisional or ventral hernia repair) and, because that procedure is 
assigned to payment group 7, CPT code 57267 should also be assigned to 
group 7.
    Response: We agree with the commenters. Our analysis shows that 
this procedure may be safely performed in the outpatient setting, and 
that the costs are similar to those for CPT code 49568. Therefore, we 
are adding CPT code 57267 to the ASC list in payment group 7 for CY 
2007.
    Comment: One commenter requested that CMS add CPT code 61795 
(Stereotactic computer assisted volumetric (navigational) procedure, 
intracranial, extracranial, or spinal) to the ASC list for CT 2007. The 
commenter stated that addition of this procedure to the ASC list would 
provide improved quality of care by providing a method that would 
minimize trauma and risk for secondary damage to patients during 
certain procedures.
    Response: We agree with the commenters that this procedure is 
appropriate for inclusion on the ASC list. It satisfies our clinical 
criteria so we are adding CPT code 61795 to the list and assigning it 
to payment group 1 with other procedures requiring similar levels of 
facility resources for CY 2007.
    Comment: Several commenters requested that CPT codes 0176T 
(Transluminal dilation of aqueous outflow canal; without retention of 
device or stent) and 0177T (Transluminal dilation of aqueous outflow 
canal; with retention of device or stent) be added to the ASC list for 
CY 2007 because they are similar to other surgical procedures on the 
eye that are frequently provided in ASCs. Commenters pointed out that 
much of the clinical investigation for these canaloplasty procedures 
was performed by surgeons in ASC settings.
    Response: These CPT codes were released by the AMA on July 1, 2006 
for implementation on January 1, 2007. We agree with the commenters 
that they are appropriate for addition to the ASC list and, based on 
the expected facility costs of the procedures and the associated single 
use devices, appropriately assigned to payment group 9 for CY 2007. 
Therefore, we will add these two procedures to the ASC list for CY 
2007.
    As discussed above, we determined that there are 10 procedures 
about which we received comments that met the criteria for inclusion on 
the ASC list for CY 2007 but that we did not propose

[[Page 68170]]

to add to the ASC list. We are adding those procedures and assigning 
them to ASC payment groups as indicated in Table 48.

  Table 48.--Additional Procedures for Addition to the ASC List for CY
                                  2007
------------------------------------------------------------------------
                                                                 Payment
                HCPCS                      Short descriptor       group
------------------------------------------------------------------------
13153................................  Repair wound/lesion add-        3
                                        on.
19295................................  Place breast clip,              1
                                        percut.
31620................................  Endobronchial us add-on         1
43257................................  Upper gi scope w/thrml          3
                                        txmnt.
57267................................  Insert mesh/pelvic flr          7
                                        add-on.
61795................................  Brain surgery using             1
                                        computer.
G0392................................  AV fistula or graft             9
                                        arterial.
G0393................................  AV fistula or graft             9
                                        venous.
0176T................................  Aqu canal dilat w/o             9
                                        retent.
0177T................................  Acq canal dilat w               9
                                        retent.
------------------------------------------------------------------------

b. Requests Not Accepted for Additions to the ASC List for CY 2007
    There were a number of procedures for which we received requests 
for addition to the ASC list that we are not adding to the ASC list 
because they do not meet the criteria set forth in the regulations as 
Sec.  416.65. Those procedures are listed in Tables 50 and 51 below.
    Our data indicate that the procedures listed in Table 49 are 
performed predominantly in physician offices and are therefore, not 
eligible for inclusion on the ASC list for CY 2007. Table 49 includes 
13 of the procedures we proposed not to add to the ASC list because 
they are furnished predominantly in the physician office setting, as 
well as an additional 22 procedures that are performed predominantly in 
physician offices that commenters to the proposed rule requested we add 
for CY 2007. One of the procedures on the list in the proposed rule, 
CPT code 31040 (Exploration behind jaw) is also not being added to the 
list for CY 2007. It is included in Table 50 rather than in Table 49 
below, because it is excluded for not meeting our clinical criteria.

  Table 49.--Procedures Not Added to CY 2007 ASC List Because They Are
            Predominantly Performed in the Physician's Office
------------------------------------------------------------------------
               CPT                            Short descriptor
------------------------------------------------------------------------
11603............................  Exc tr-ext mlg+marg 2.1-3 cm.
20610............................  Drain/inject, joint/bursa.
28124............................  Partial removal of toe.
40812............................  Excise/repair mouth lesion.
45300............................  Proctosigmoidoscopy dx.
45303............................  Proctosigmoidoscopy dilate.
45330............................  Diagnostic sigmoidoscopy.
46221............................  Ligation of hemorrhoid(s).
46604............................  Anoscopy and dilation.
46614............................  Anoscopy, control bleeding.
46900............................  Destruction, anal lesion(s).
46910............................  Destruction, anal lesion(s).
46916............................  Destruction, anal lesion(s).
62367............................  Analyze spine infusion pump.
62368............................  Analyze spine infusion pump.
64402............................  N block inj, facial.
64405............................  N block inj, occipital.
64408............................  N block inj, vagus.
64412............................  N block inj, spinal accessor.
64413............................  N block inj, cervical plexus.
64418............................  N block inj, suprascapular.
64425............................  N block inj, ilio-ing/hypogi.
64435............................  N block inj, paracervical.
64445............................  N block inj, sciatic, sng.
64505............................  N block, spenopalatine gangl.
64508............................  N block, carotid sinus s/p.
64555............................  Implant neuroelectrodes.
64612............................  Destroy nerve, face muscle.
67028............................  Injection eye drug.
67105............................  Repair detached retina.
67110............................  Repair detached retina.
67145............................  Treatment of retina.
67210............................  Treatment of retinal lesion.
67221............................  Ocular photodynamic ther.
67228............................  Treatment of retinal lesion.
------------------------------------------------------------------------

    Comment: Many commenters indicated that CMS should remove the 
criterion that procedures performed predominantly in the physician's 
office are not eligible for inclusion on the ASC list for CY 2007 and, 
specifically, that CMS add CPT code 45330 (Diagnostic sigmoidoscopy) to 
the ASC list for CY 2007.
    Response: The current criteria were used to make decisions 
regarding inclusion on the CY 2007 ASC list. We did not propose to 
alter these criteria prior to implementation of the revised payment 
system, as proposed for CY 2008. Although we proposed to allow 
procedures predominantly performed in physician offices to be paid 
under the revised ASC payment system, we will not make final any 
proposed changes to the criteria for the revised system until we have 
considered the public comments to that proposal. The comment period 
will not close for that proposal until after this final rule with 
comment period has been published. Therefore, for CY 2007, we will 
continue to adhere to the current criteria for inclusion on the list 
and will not add procedures that are provided predominantly in the 
physician office setting to the list.
    Procedures that are displayed in Table 49 above include office-
based procedures recommended for addition to the ASC list by commenters 
to the CY 2007 OPPS proposed rule. Procedures that are predominately 
office-based do not meet our criteria for inclusion on the ASC list. 
Thus, we are finalizing our proposal to not include on the ASC list any 
of the services performed predominantly in physician offices as 
displayed in Table 49.
    In the CY 2007 OPPS proposed rule, we indicated that we were not 
proposing to add to the ASC list 14 procedures for which we received 
requests for addition because our medical advisors believe that those 
procedures do not meet the clinical criteria (Sec.  416.65) for 
addition. Our medical advisors believed that the procedures listed in 
Table 43 of the CY 2007 OPPS proposed rule (71 FR 49629) are of a type 
that:
     Require an overnight or inpatient stay;
     Require a total of 90 minutes of operating time or 4 hours 
or more of recovery time;
     Require major or prolonged invasion of body cavities or 
involve major blood vessels;
     Are generally emergent or life-threatening; or
     Are of a type that result in extensive blood loss.
    These characteristics make procedures ineligible for addition to 
the list of ASC procedures. The 14 procedures that we proposed to not 
be added to the list based on clinical criteria, as well as additional 
procedures for which we received requests in comments to the August 23, 
2006 proposed rule that did not meet the criteria, are displayed below 
in Table 50.

 Table 50.--Procedures Not Added to the CY 2007 ASC List Because They Do
     Not Meet Current Clinical Criteria for Addition to the ASC List
------------------------------------------------------------------------
                    CPT                           Short descriptor
------------------------------------------------------------------------
21390.....................................  Treat eye socket fracture.
21406.....................................  Treat eye socket fracture.
21407.....................................  Treat eye socket fracture.
27412.....................................  Autochondrocyte implant
                                             knee.
27415.....................................  Osteochondral knee
                                             allograft.

[[Page 68171]]

 
29866.....................................  Autgrft implnt, knee w/
                                             scope.
29867.....................................  Allgrft implnt, knee w/
                                             scope.
29868.....................................  Meniscal trnspl, knee w/
                                             scpe.
31040.....................................  Exploration behind jaw.
35470.....................................  Repair arterial blockage.
35471.....................................  Repair arterial blockage.
35475.....................................  Repair arterial blockage.
35476.....................................  Repair venous blockage.
35490.....................................  Atherectomy, percutaneous.
35492.....................................  Atherectomy, percutaneous.
35493.....................................  Atherectomy, percutaneous.
35494.....................................  Atherectomy, percutaneous.
35495.....................................  Atherectomy, percutaneous.
37205.....................................  Transcath IV stent,
                                             percutaneous.
37206.....................................  Transcath IV stent/perc,
                                             add'l.
42844.....................................  Extensive surgery throat.
47562.....................................  Laparoscopic
                                             cholecystectomy.
47563.....................................  Laparo cholecystectomy/
                                             graph.
47564.....................................  Laparo cholecystectomy/
                                             explr.
60210.....................................  Partial thyroid excision.
63001.....................................  Removal of spinal lamina.
63003.....................................  Removal of spinal lamina.
63005.....................................  Removal of spinal lamina.
63011.....................................  Removal of spinal lamina.
63020.....................................  Neck spine disk surgery.
63030.....................................  Low back disk surgery.
63035.....................................  Spinal disk surgery add-on.
63040.....................................  Laminotomy single, cervical.
63042.....................................  Laminotomy, single lumbar.
63047.....................................  Removal of spinal lamina.
63048.....................................  Remove spinal lamina add-on.
63655.....................................  Implant neuroelectrodes.
64448.....................................  N block inj fem, cont inf.
64449.....................................  N block inj, lumbar plexus.
------------------------------------------------------------------------

    Comment: Some commenters addressed many of the codes that we did 
not propose to add because we believed that they did not meet the 
clinical criteria for inclusion on the ASC list for CY 2007. The 
commenters disagreed with some of our clinical determinations and 
stated that the procedures were safe for performance on an outpatient 
basis, satisfy our clinical criteria and should be included on the ASC 
list. Further, a few commenters noted that, although we proposed to 
exclude those 14 procedures from the list for CY 2007, we also proposed 
to add some of them to the list for payment under the CY 2008 revised 
payment system. They believed that we should add those procedures now 
rather than wait until CY 2008.
    Response: Our medical advisors reviewed all of the procedures 
requested for addition in the comments. They did not find reason to 
change their determinations for any of the procedures included in Table 
50. At the least, all of those procedures require longer than 4 hours 
of recovery time and some of them require overnight stays or involve 
major blood vessels.
    As noted by several of the commenters, we did propose to allow 
Medicare payment for some of the procedures under the revised ASC 
payment system for CY 2008. Integral to the proposal for CY 2008 is a 
revision of the criteria used to determine for which procedures 
Medicare would provide ASC facility payment. We did not propose any 
revision of the criteria for CY 2007 and clearly indicated in the 
proposed rule that all decisions regarding the ASC list for CY 2007 
would be made according to the current criteria.
    We are finalizing our proposal not to include any of the services 
that do not meet current clinical criteria for addition to the ASC list 
that are displayed in Table 50 above for CY 2007, with modification to 
also not include procedures recommended by commenters to the CY 2007 
proposed rule that do meet current clinical criteria for addition to 
the ASC list.
    For these reasons, we are making final our decisions not to add any 
of the procedures included in Table 50 to the ASC list for CY 2007.
    Comment: A number of commenters requested that CMS add to the ASC 
list certain procedures that have very low facility costs and for which 
payment is included in that for other procedures. The requested 
procedures are currently assigned the following HCPCS codes:

 36100-(Establish access to artery)
 36120-(Establish access to artery)
 36140-(Establish access to artery)
 6145-(Artery to vein shunt)
 6200-(Place catheter in aorta)
 6215-(Place catheter in artery)
 6216-(Place catheter in artery)
 36217-(Place catheter in artery)
 36218-(Place catheter in artery)
 36245-(Place catheter in artery)
 36246-(Place catheter in artery)
 36247-(Place catheter in artery)
 36248-(Place catheter in artery)
 38792-(Identify sentinel node)
 62290-(Inject spine disk x-ray)
 62291-(Inject spine disk x-ray)
 66990-(Ophthalmic endoscope add-on)
 G0289-(Arthro, loose body + chondo)

    The commenters believed that these procedures were appropriate for 
addition to the ASC list so that the facilities could receive separate 
payment for them.
    Response: Many of the requested procedures for addition to the list 
are procedures that are typically performed as minor services that are 
integrally related to the provision of the primary surgical procedure. 
Our policy in the ASC payment system is not necessarily to pay 
separately for each associated component of procedures, even if it is 
described by a separate HCPCS code, but rather to bundle payment for 
those components together into the payment for the primary surgical 
procedure. Many of those minor procedures that commenters requested we 
add to the ASC list are paid as part of the payment for the primary 
surgical service. For instance, Medicare does not make a separate 
facility payment for CPT code 36145, Introduction of needle or 
intracatheter; arteriovenous shunt created for dialysis (cannula, 
fistula, or graft). The introduction of the needle or intracatheter 
described here is performed as an integral step that is part of the 
primary procedure, and it is not associated with any particular 
procedure but may be used in many different ones. Presumably, the 
primary procedure could not be performed unless the needle or 
intracatheter were first placed to provide access to the site for 
treatment.
    Therefore, we are not adding to the ASC list for CY 2007 any 
procedure that we have identified as a minor service that is integrally 
related to the provision of the primary surgical procedure.
7. Requests for Payment Increases for Procedures on the Current ASC 
List
    Comment: A few commenters requested that we assign CPT code 57288 
(Sling operation for stress incontinence (eg, fascia or synthetic)) to 
a higher ASC payment level. The commenters stated that because

[[Page 68172]]

Medicare does not allow separate payment for the synthetic mesh 
required for performing the procedure, payment at the current level is 
inadequate to cover the cost of the service. They reported that the 
costs for the synthetic mesh are between $700 and $850 and that the 
$717 payment made to the ASC does not cover the costs of providing the 
service. They stated that if CMS considers the sling material to be 
bundled into the ASC facility fee, then CPT code 57288 should be 
assigned to payment group 9.
    Response: As we explained in our response to comments in the 
proposed rule related to CPT code 51992 (Laparoscopy, surgical; sling 
operation for stress incontinence (eg, fascia or synthetic)) (71 FR 
49630), we realize that the synthetic material for the sling may be 
costly, but there is no identifiable HCPCS code available for use in 
ASCs to report the material, and such material is not eligible for 
separate payment from Medicare in the ASC or in any other setting. 
Further, CPT code 57288, like CPT code 51992, describes a procedure 
that may be performed using synthetic material or fascia. As such, we 
cannot know whether the more costly synthetic material is used in any 
specific procedure and do not believe it is appropriate to fully 
incorporate the synthetic supply costs into the payment for all of the 
procedures performed. We continue to believe that ASC payment group 5 
is an appropriate assignment for the procedure, and therefore, as we 
proposed, we are not changing that assignment.
    Comment: One commenter requested that CMS assign CPT codes 58353 
(Endometrial ablation, thermal; without hysteroscopic guidance) and 
58563 (Hysteroscopy, surgical; with endometrial ablation (eg, 
endometrial resection, electrosurgical ablation, thermoablation)) to 
payment group 9 instead of to group 4 to which they are currently 
assigned. They stated that because CMS assigned CPT code 58565 
(Hysteroscopy, surgical; with bilateral fallopian tube cannulation to 
induce occlusion by placement of permanent implants) to payment group 9 
because we believed that it was more resource-intensive than other 
procedures assigned to group 4, that CPT codes 58353 and 58563 should 
also be assigned to group 9. The commenters indicated that those two 
procedures use transcervical, single use devices and have similar 
resource intensity to CPT code 58565. The commenters did not provide 
any cost information for either of the procedures.
    Response: We examined cost data available to us regarding the 
facility or office costs associated with performing those procedures in 
other outpatient settings (physician offices and hospital outpatient 
departments). These are the best data available to us because we have 
no cost data for those procedures in ASCs. We agree with the commenters 
that payment in group 4 may not be adequate for either of the 
procedures, and we believe that the costs for CPT code 58563 are higher 
than those for CPT code 58353 due to the expensive guidance equipment 
used in the procedure. Therefore, we are assigning CPT code 58353 to 
payment group 7 for CY 2007 and CPT code 58563 to payment group 9 for 
CY 2007.
8. Other Comments on the May 4, 2005 Interim Final Rule
    In the May 4, 2005 interim final rule (70 FR 23690), we invited 
public comments on the payment assignments for specific procedure codes 
that we added to the ASC list in that rule that had not been proposed 
for addition to the ASC list in the November 26, 2004 proposed rule (69 
FR 69178). We received comments on 14 of those newly-added procedures. 
A summary of those comments and our treatment of them for CY 2007 is 
discussed below.
    Comment: Several commenters requested that we delay adding to the 
ASC list CPT codes 33212 (Insertion or replacement of pacemaker pulse 
generator only; single chamber, atrial or ventricular), 33213 
(Insertion or replacement of pacemaker pulse generator only; dual 
chamber), and 33233 (Removal of permanent pacemaker pulse generator) 
until we implement the new ASC payment system.
    Response: We added these procedures to the ASC list in response to 
a request from a commenter. Our medical advisors evaluated the request 
and determined that these were appropriate procedures for performance 
in the ASC setting. We continued to believe that the procedures were 
appropriate for performance in the ASC and saw no reason to remove them 
from the list at this time.
    We proposed in the CY 2007 OPPS proposed rule to retain CPT codes 
33212, 33214, and 33233 on the ASC list, with their current payment 
level assignments.
    We received no further comments on this proposal and, therefore, as 
we proposed, in this final rule with comment period, we are not making 
any changes to the ASC assignments for CPT codes 33212, 33213, and 
33233.
    Comment: Two commenters requested that we reassign CPT codes 57155 
(Insertion of uterine tandems and/or vaginal ovoids for clinical 
brachytherapy) and 58346 (Insertion of Heyman capsules for clinical 
brachytherapy) to the highest ASC payment group. The commenters 
believed that payment at a higher level was necessary in order to cover 
the costs of the equipment and supplies used in performing the 
procedures.
    Response: We reviewed the OPPS cost data for the procedures as the 
best indicator available to us of facility costs and found that the 
median costs for CPT codes 57155 and 58346 when furnished in the 
hospital outpatient department were $506 and $364, respectively. We do 
not have median cost data for the procedures performed in the ASC but 
the ASC payment amount for both services is $446, which is within the 
range of the procedures' median costs in the generally more costly 
hospital outpatient setting. This led us to believe that the $446 
payment in the ASC is quite adequate.
    We proposed in the CY 2007 OPPS proposed rule to retain CPT codes 
57155 and 58346 in ASC payment group 2.
    We received no comments on this proposal and, therefore, as we 
proposed, in this final rule with comment period, we are not assigning 
the procedures to higher ASC payment groups.
    Comment: Several commenters requested that CMS remove from the list 
CPT codes 36475 (Endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, 
percutaneous, radiofrequency; first vein); 36476 (Endovenous ablation 
therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency; second and 
subsequent veins in single extremity, each through separate access 
sites); 36478 (Endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, 
percutaneous, laser; first vein); and 36479 (Endovenous ablation 
therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, laser; second and subsequent 
veins treated in a single extremity, each through separate access 
sites). The commenters suggested that if we were unwilling to remove 
them from the list, that we assign the procedures to a higher payment 
group. They believed that the procedures required significantly more 
facility resources than other procedures with which they are currently 
grouped in payment level 3. The commenters explained that if the 
procedures were excluded from the list, more adequate payments would be 
made to physicians under the MPFS for the required resources.

[[Page 68173]]

    Response: We added these procedures to the list in response to 
public comments, because we believe they met all the criteria for 
addition to the ASC list. We initially assigned the codes to ASC 
payment group 3, consistent with other procedures with similar clinical 
indications. We continued to believe that these procedures were 
appropriate for performance in the ASC setting and did not propose to 
remove them from the list. However, we agreed with the commenters' 
point that the procedures require significantly more facility resources 
than traditional vein removal procedures, and proposed to assign them 
for CY 2007 to payment group 9 in the preamble of the CY 2007 OPPS 
proposed rule. We note that these codes mistakenly were published in 
Addendum AA of the proposed rule with assignment to payment group 8, 
and in the supporting public data files for the CY 2007 proposed rule 
as assigned to payment group 8.
    Comment: Many commenters also expressed their concerns about the 
lack of clarity of the proposed payment group assignments for CPT codes 
36475, 36476, 36478, and 36479 for CY 2007. Commenters noted the high 
cost of the procedures, which were assigned to payment group 3, and 
stated their belief that payment at level three is so low that that 
ASCs could not afford to provide the services at that rate. Commenters 
requested that CMS confirm that these CPT codes were assigned to 
payment group 9, and finalize our proposal for their CY 2007 treatment.
    Response: We proposed that all four of these procedures be assigned 
to payment group 9 for CY 2007. We recognize that our data files caused 
confusion, and we appreciate the commenters bringing the 
inconsistencies to our attention. We continue to believe that these 
services should be assigned to payment group 9 for CY 2007.
    Therefore, we are finalizing our proposal to retain these 
procedures on the ASC list and assigning them to ASC payment group 9 
for CY 2007.
    Comment: Two comments requested that we assign CPT code 46947 
(Hemorrhoidopexy by stapling) to a higher ASC payment group. The 
commenters stated that due to the cost of the stapler used in the 
procedure, the resources required for this procedure are not similar to 
the other surgical procedures for the treatment of hemorrhoids that are 
also assigned to ASC payment group 3. The commenters suggested that it 
would be more appropriate to assign this procedure to ASC payment group 
7.
    Response: We agreed with the commenters and proposed in the CY 2007 
proposed rule to assign the procedure to ASC payment group 7 for CY 
2007. We received no comments on this proposal and, therefore, are 
finalizing our assignment of CPT code 46947 to ASC payment group 7 for 
CY 2007.
    Comment: One commenter requested that we allow separate payment for 
the material used as the sling in the procedure described by CPT code 
51992 (Laparoscopy, surgical; sling operation for stress incontinence 
(e.g. fascia or synthetic)). The commenter stated that without separate 
payment for the sling material, the Medicare payment for performing the 
procedure is inadequate to cover the service. The commenter also stated 
that there is no specific HCPCS code to use for billing the synthetic 
sling material.
    Response: We added CPT code 51992 to the ASC list in the last 
update in response to comments. We assigned CPT code 51992 to ASC 
payment group 5, the same ASC payment group to which other procedures 
to treat stress incontinence are assigned. As discussed previously, we 
realize that the synthetic material for the sling may be costly, but 
there is no identifiable HCPCS code available for use in ASCs to report 
the material, and such material is not eligible for separate payment 
from Medicare in the ASC or in any other setting. Further, CPT code 
51992 describes a procedure that may be performed using synthetic 
material or fascia. As such, we cannot know whether the more costly 
synthetic material is used in any specific procedure and do not believe 
it is appropriate to fully incorporate the synthetic supply costs into 
the payment for all of the procedures performed. We continue to believe 
that ASC payment group 5 is an appropriate assignment for the 
procedure, and therefore, as we proposed, we are not changing that 
assignment.
    Comment: One commenter requested that we make separate payment for 
the microinserts that are used in performing CPT code 58565 
(Hysteroscopy, surgical; with bilateral fallopian tube cannulation to 
induce occlusion by placement of permanent implants). The commenter 
stated that there is no specific HCPCS Level II code to describe the 
microinserts and, thus, separate billing for them currently is not 
possible.
    Response: We added CPT code 58565 to the ASC list in the last 
update in response to public comment. We assigned the procedure to ASC 
payment group 4 with other procedures with similar clinical 
indications. After further review, we were convinced that the procedure 
described by CPT code 58565 was significantly more resource-intensive 
than the other procedures in ASC payment group 4 and, therefore, 
proposed to reassign the procedure to ASC payment group 9 for CY 2007.
    We received no comments to this proposal and therefore are making 
final our proposal to assign CPT code 58565 to ASC payment group 9 for 
CY 2007.
    Comment: Several comments requested that CMS issue instructions to 
permit separate payment for the catheters that are inserted during the 
procedures described by CPT codes 19296 (Placement of radiotherapy 
after loading balloon catheter into the breast for interstitial 
radioelement application following partial mastectomy, includes imaging 
guidance; on date separate from partial mastectomy) and 19298 
(Placement of radiotherapy after loading brachytherapy catheters into 
the breast for interstitial radioelement application following partial 
mastectomy, includes imaging guidance).
    One commenter supported our inclusion of CPT code 19296 on the ASC 
list in payment group 9, but asserted that separate payment should also 
be provided for the balloon catheter inserted during the procedure. 
With regard to CPT code 19298, other commenters also stated that the 
payment level is inadequate and that separate payment should be allowed 
for the catheters inserted during the procedure. One of the commenters 
explained that the catheters used to perform the procedure described by 
CPT code 19298 are not high cost items (about $18.50 each) but these 
procedures typically use 30 catheters which makes the catheters a 
significant cost factor in performing the procedure.
    Response: In the CY 2007 proposed rule, we noted that the catheters 
used in these procedures are classified as surgical supplies and, as 
such, are not included on the DMEPOS fee schedule and are, therefore, 
not eligible for separate payment in the ASC. Payments for the costs of 
the catheters are packaged into the payments for performing the 
procedures. Currently CPT code 19298 is assigned to ASC payment group 
1. Based on the information provided by the commenters, we were 
persuaded that reassignment to a higher ASC payment group was warranted 
and proposed to reassign the CPT code 19298 to ASC payment group 9 for 
CY 2007.
    We received no comments about this proposal and, therefore, as we 
proposed, we are reassigning CPT code 19298 to ASC payment group 9 and 
will retain

[[Page 68174]]

CPT code 19296 in payment group 9 and payment for the balloon catheter 
will continue to be included in that rate.

C. Regulatory Changes for CY 2007

    As stated earlier, in the CY 2007 proposed rule, we proposed a 
revised payment system for ASCs to be implemented effective January 1, 
2008, including revisions to the ASC list for CY 2008, the ratesetting 
method, and the applicable ASC regulations to incorporate the 
requirements and payments for ASC facility services under the proposed 
revised ASC system. We expect that a final rule implementing the 
revised ASC payment system will be published separately in the spring 
of 2007. The revised ASC payment system would not take effect until 
January 1, 2008. However, we need to revise our current regulations at 
part 416, subparts D and E to ensure that the rules governing our 
current system are clearly distinguishable from those that will apply 
to the revised system beginning January 1, 2008. Therefore, as we 
proposed, we are revising Subparts D and E of Part 416 of the 
regulations to reflect that these are the rules governing the APC 
payment system prior to January 1, 2008, and redesignating the existing 
Subpart F as Subpart G under Part 416 to codify the rules governing the 
ASC payment adjustment for NTIOLs. In addition, we are revising 
existing--
     Sec.  416.1 (a)(2) and (a)(3) (under Basis and scope) and 
the definition of ``Facility'' under Sec.  416.2 to remove the obsolete 
reference to ``a hospital outpatient department,'' to add provisions of 
section 5103 of Public Law 109-171, and applicable provisions of Public 
Law 108-173.
     Sec.  416.65 (Covered surgical procedures) to modify the 
introductory text to clearly denote the section s application to 
covered surgical procedures furnished before January 1, 2008. In 
addition, we are removing the obsolete cross-reference in paragraph 
(a)(4) to Sec.  405.310 and replacing it with the correct cross-
reference to Sec.  411.15.
     Sec.  416.125 (ASC facility services payment rate) to 
incorporate the limitation on payment imposed by section 5103 of Public 
Law 109-171.
     Sec.  488.1 (Definitions) to correct a longstanding error 
by adding ambulatory surgical centers to the definition of a supplier 
in conformance with section 1861(d) of the Act.
    We also are revising the headings of Subparts D and E and adding 
new Sec. Sec.  416.76 and 416.121 to Subparts D and E, respectively, to 
clearly state that the provisions of Subparts D and E apply to services 
furnished before January 1, 2008.
    In addition, we are making two technical changes: revising Sec.  
416.120 to replace the incorrect cross-reference to ``Part 413'' with 
the correct cross-reference to ``Part 419''; and deleting Sec.  416.150 
(Beneficiary appeals) because it does not conform with the appeals 
process provisions of 42 CFR Part 405, subparts H and I.
    We received no comments on these proposed revisions and are 
finalizing them as proposed without modification.

D. Implementation of Section 1834(d) of the Act

    Sections 1834(d)(2) and (3) of the Act require that the computed 
beneficiary coinsurance amount for screening flexible sigmoidoscopy and 
screening colonoscopy services provided in hospital outpatient 
departments and ASCs be equal to 25 percent of the payment amount. They 
also require Medicare to pay the lesser of the ASC or OPPS payment 
amount for those screening services in each geographic area.
    For CY 2007, the OPPS payment amount will be limited to the lesser 
ASC payment amount for screening colonoscopies. Medicare payment for 
screening flexible sigmoidoscopies will not be affected in CY 2007 
because those services are not currently paid for in ASCs. There will 
be no effect on the payment amount to ASCs for screening colonoscopies. 
However, beginning in CY 2007, beneficiaries will be responsible for 
paying a 25-percent coinsurance for screening colonoscopies when 
provided in ASCs. Beneficiaries have been paying a 25-percent 
coinsurance for such services when provided in hospital outpatient 
departments.
    Although the provision is not new, it has not been implemented for 
ASCs due to ongoing instability in that payment system and uncertainty 
regarding plans for a revised payment system. There was uncertainty for 
several years about whether data gathered in a 1994 CMS-sponsored 
survey of ASC costs would be used to develop new rates for ASCs and, if 
so, how best to configure the payment methodology.
    The MMA requires the implementation of a revised system no later 
than January 1, 2008. However, section 5103 of the Deficit Reduction 
Act of 2005 (DRA) requires CMS to make some substantial payment rate 
changes for ASCs in CY 2007. Implementation of section 5103 of the DRA 
requires that carriers and ASCs make significant claims processing 
system changes. Since passage of the MMA, we have generally followed a 
policy of making as few changes to the current ASC payment system as 
possible prior to implementation of the MMA-mandated revised payment 
system, in order to minimize the administrative burden on ASCs. 
However, because changes to the system are being made for CY 2007 to 
comply with the DRA, we believe that we should also implement the 
requirements of section 1834(d) of the Act at the same time.
    We are confident that implementation of the coinsurance change 
required by section 1834(d) of the Act, in addition to changes required 
to comply with the DRA, will not interfere with ASCs' ability to 
provide services as usual.
    Currently, Medicare provides an ASC facility payment for two 
screening colonoscopy procedures reported by HCPCS codes G0105 
(Colorectal cancer screening; colonoscopy on individual at high risk) 
and G0121 (Colorectal cancer screening; colonoscopy on individual not 
meeting criteria for high risk), and not for any screening flexible 
sigmoidoscopies. Those are the only procedures that will be affected by 
the higher coinsurance amounts in ASCs in CY 2007. Beginning January 1, 
2007, beneficiaries receiving services described by G0105 or G0121 in 
ASCs are responsible for a 25-percent coinsurance rather than the 
current 20 percent.
    Sections 1834(d)(2) and (d)(3) of the Act also require Medicare to 
pay the lesser of the ASC or OPPS payment amount for screening flexible 
sigmoidoscopies and screening colonoscopies. Medicare will not make 
payment to ASCs for screening sigmoidoscopies in CY 2007, so there is 
no payment comparison to be made for those services. This requirement 
will not impact ASC payments for the above listed screening 
colonoscopies in CY 2007, because the ASC amount will be lower than the 
OPPS payment calculated according to the standard OPPS methodology, 
prior to application of this requirement.

E. Implementation of Section 5103 of Public Law 109-171 (DRA)

    As noted in section XVII.A.1. of this preamble, section 5103 of 
Public Law 109-171 requires us to substitute the OPPS payment amount 
for the ASC standard overhead amount for surgical procedures performed 
at an ASC on or after January 1, 2007, but prior to the revised payment 
system when the ASC standard overhead amount exceeds the OPPS payment 
amount for the procedure. In Addendum AA of this final rule with 
comment period, we identify the HCPCS codes that we

[[Page 68175]]

believe will be subject to section 5103 based on a comparison of the 
final CY 2007 OPPS payment rates and the ASC standard overhead amounts 
that are effective in CY 2007. In addition, as we proposed, we are 
adding paragraph (c) to Sec.  416.125 to reflect this change.
    Comment: A few commenters asked that CMS not implement the payment 
limits because, in some cases, those payment decreases would result in 
payments that would be inadequate to cover the costs of the procedures.
    Response: Implementation of the payment limitations required by the 
DRA is a statutory requirement. Therefore, we are finalizing the 
payment limits as required and as presented in our proposed rule 
without modification.

F. Modification of the Current ASC Process for Adjusting Payment for 
New Technology Intraocular Lenses (NTIOLs)

1. Background
    At the inception of the ASC benefit on September 7, 1982, Medicare 
paid 80 percent of the reasonable charge for IOLs supplied for 
insertion concurrent with or following cataract surgery performed in an 
ASC (47 FR 34082, August 5, 1982). Section 4063(b) of OBRA 1987, Public 
Law 100-203, amended the Act to mandate that we include payment for an 
IOL furnished by an ASC for insertion during or following cataract 
surgery as part of the ASC facility fee for insertion of the IOL, and 
that the facility fee include payment that is reasonable and related to 
the cost of acquiring the class of lens involved in the procedure.
    Section 4151(c)(3) of the Omnibus Budget Reconciliation Act of 1990 
(OBRA 1990), Public Law 101-508, froze the IOL payment amount at $200 
for IOLs furnished by ASCs in conjunction with surgery performed during 
the period beginning November 5, 1990, and ending December 31, 1992. We 
continued paying an IOL allowance of $200 from January 1, 1993, through 
December 31, 1993.
    Section 13533 of the Omnibus Budget Reconciliation Act of 1993 
(OBRA 1993), Public Law 103-66, mandated that payment for an IOL 
furnished by an ASC be equal to $150 beginning January 1, 1994, through 
December 31, 1998.
    Section 141(b)(1) of the Social Security Act Amendments of 1994 
(SSAA 1994), Public Law 103-432, required us to develop and implement a 
process under which interested parties may request a review of the 
appropriateness of the payment amount for insertion of an IOL, to 
ensure that the facility fee for the procedure includes payment that is 
reasonable and related to the cost of acquiring a lens that belongs to 
a class of NTIOLs.
    In the February 8, 1990 Federal Register (55 FR 4526), we published 
a final notice entitled ``Revision of Ambulatory Surgery Center Payment 
Rate Methodology,'' which implemented Medicare payment for an IOL 
furnished at an ASC as part of the ASC facility fee for insertion of 
the IOL.
    In the June 16, 1999 Federal Register (64 FR 32198), we published a 
final rule entitled ``Adjustment in Payment Amounts for New Technology 
Intraocular Lenses Furnished by Ambulatory Surgical Centers,'' to add 
Subpart F (Sec. Sec.  416.180 through 416.200) to 42 CFR Part 416, 
which established a process for adjusting payment amounts for insertion 
of a class of NTIOLs furnished by ASCs.
    Our current regulations at Sec. Sec.  416.180 through 416.200 
define the terms relevant to the process, establish the payment review 
process, and establish $50 as the payment adjustment amount that is 
added to the ASC facility fee for insertion of a lens that CMS 
determines is an NTIOL. Section 416.200 provides that the payment 
adjustment applies for a 5-year period that begins when we recognize 
the first lens that establishes a class of NTIOLs. In accordance with 
Sec.  416.200(b), insertion of a lens that we subsequently recognize as 
belonging to an existing NTIOL class would receive the payment 
adjustment for the remainder of the 5-year period established for the 
class. Section 416.185(f)(2) provides that after July 16, 2002, we have 
the option of changing the $50 adjustment amount through proposed and 
final rulemaking in connection with ASC services.
    Since June 16, 1999, we have issued a series of Federal Register 
notices to list lenses for which we received requests for a NTIOL 
payment adjustment and to solicit comments on those requests, or to 
announce the lenses that we have determined meet the criteria and 
definition of NTIOLs. We last published a Federal Register notice 
pertaining to NTIOLs on April 28, 2006 (71 FR 25176).
a. Current ASC Payment for Insertion of IOLs
    The current ASC payment groups, payment rates and procedural HCPCS 
codes for cataract extraction with IOL insertion are as follows:
    Payment Group 6--$826 ($676 + $150 IOL Allowance)
     CPT code 66985, Insertion of intraocular lens prosthesis 
(secondary implant), not associated with concurrent cataract removal
     CPT code 66986, Exchange of intraocular lens
    Payment Group 8--$973 ($823 + $150 IOL allowance)
     CPT code 66982, Extracapsular cataract removal with 
insertion of intraocular lens prosthesis (one stage procedure), manual 
or mechanical technique (for example, irrigation and aspiration or 
phacoemulsification), complex, requiring devices or techniques not 
generally used in routine cataract surgery (for example, iris expansion 
device, suture support for intraocular lens, or primary posterior 
capsulorrhexis) or performed on patients in the amblyogenic 
developmental stage
     CPT code 66983, Intracapsular cataract extraction with 
insertion of intraocular lens prosthesis (one stage procedure)
     CPT code 66984, Extracapsular cataract removal with 
insertion of intraocular lens prosthesis (one stage procedure), manual 
or mechanical technique (for example, irrigation and aspiration or 
phacoemulsification)
b. Classes of NTIOLs Approved for Payment Adjustment
    Since implementation of the process for adjustment of payment 
amounts for NTIOLs that was established in the June 16, 1999 Federal 
Register, we have approved three classes of NTIOLs, as shown in Table 
51 below:

                          Table 51.--Classes of NTIOLs Approved for Payment Adjustment
----------------------------------------------------------------------------------------------------------------
                                            $50 Approved for
  NTIOL category        HCPCS code       services  furnished on    NTIOL characteristic      IOLs eligible for
                                                or after                                        adjustment
----------------------------------------------------------------------------------------------------------------
1.................  Q1001.............  May 18, 2000, through    Multifocal.............  Allergan AMO Array
                                         May 18, 2005.                                     Multifocal lens,
                                                                                           model SA40N.

[[Page 68176]]

 
2.................  Q1002.............  May 18, 2000, through    Reduction in              STAAR Surgical
                                         May 18, 2005.            Preexisting              Elastic Ultraviolet-
                                                                  Astigmatism.             Absorbing Silicone
                                                                                           Posterior Chamber IOL
                                                                                           with Toric Optic,
                                                                                           models AA4203T,
                                                                                           AA4203TF, and
                                                                                           AA4203TL.
3.................  Q1003.............  February 27, 2006,       Reduced Spherical        Advanced Medical
                                         through February 26,     Aberration.              Optics (AMO)
                                         2011.                                             Tecnis[supreg] IOL
                                                                                           models Z9000, Z9001,
                                                                                           and ZA9003; Alcon
                                                                                           Acrysof IQ Model
                                                                                           SN60WF.
----------------------------------------------------------------------------------------------------------------

32. Proposed and Final Changes
a. Process for Recognizing IOLs as Belonging to an Active NTIOL Class
    Currently, we accept and review applications for inclusion in an 
active NTIOL class on a continuous basis throughout the year in 
accordance with Sec. Sec.  416.180 through 416.200 of the regulations. 
As we proposed in the CY 2007 OPPS proposed rule, we are continuing 
this established process and updating and streamlining it, as discussed 
below, to specify the request and comment review process, the 
information that a request must include to be accepted for review, the 
specific factors to be considered in evaluating requests, and the 
process to provide notification of determinations. As stated in section 
XVII.C. of this preamble, we are redesignating existing Subpart F of 
Part 416 as Subpart G, which will include the regulations pertaining to 
the ASC payment adjustment for NTIOLs. In addition, we are revising 
redesignated Subpart G to include revisions to existing Sec.  416.180, 
Sec.  416.185, Sec.  416.190, Sec.  416.195, and Sec.  416.200 to 
reflect the changes that we are making to this process.
    One of the regulatory changes that we are making is to revise 
existing Sec.  416.180 to establish the basis and scope for this ASC 
payment adjustment. This revision eliminates the definitions currently 
included in that section for ``Class of new technology intraocular 
lenses (IOLs),'' ``Interested party,'' ``New technology IOL,'' and 
``New technology subset.'' We do not believe that we need to retain 
these definitions because additional revisions that we are making to 
the regulations at Part 416 will eliminate the term ``interested 
party'' from Sec. Sec.  416.185(c) and 416.190 and the term ``new 
technology subset'' from Sec. Sec.  416.185(g), 416.200(a), (b), and 
(c) and further clarify the terms ``new technology IOL'' and ``class of 
new technology intraocular lenses (IOLs).'' We received no comments on 
the changes we proposed to Sec.  416.180. Accordingly, we are revising 
Sec.  416.180 as we proposed, to reflect the Basis and Scope of Subpart 
G of Part 416.
    The other changes that we are making to Part 416, pertaining to the 
ASC payment adjustment for NTIOLs, are discussed below.
b. Public Notice and Comment Regarding Adjustments of NTIOL Payment 
Amounts
    As we proposed, we are updating and streamlining the process for 
determining whether an IOL that is to be inserted during or subsequent 
to cataract extraction qualifies for payment adjustment as a NTIOL, as 
set forth in existing Sec.  416.185 of our regulations. The basis for 
the current NTIOL payment review process was enacted in 1994 and has 
been implemented through a series of separate Federal Register notices 
specific to NTIOLs. We are modifying the current process of using 
separate Federal Register notices to notify the public of requests to 
review lenses for membership in new NTIOL classes, to solicit public 
comment on requests, and to notify the public of CMS determinations 
concerning new classes of NTIOLs for which an ASC payment adjustment 
would be made. We are specifying that these NTIOL-related notifications 
will be fully integrated into the annual notice and comment rulemaking 
for updating the ASC payment rates, the specific payment system in 
which NTIOL payment adjustments are made. Given that the NTIOL payment 
adjustments are applicable to ASC services and that our proposal for 
updating the new ASC payment system to be implemented in January 2008 
anticipates an annual update process in coordination with notice and 
comment rulemaking on the OPPS, aligning the NTIOL process with this 
annual update will promote coordination and efficiency, thereby 
streamlining and expediting the NTIOL notification, comment, and review 
process.
    Specifically, we are establishing the following process:
     We will announce annually in the Federal Register document 
that proposes the update of ASC payment rates for the following 
calendar year, a list of all requests to establish new NTIOL classes 
accepted for review during the calendar year in which the proposal is 
published and the deadline for submission of public comments regarding 
those requests. The deadline for receipt of public comments will be 30 
days following publication of the list of requests.
    In the Federal Register document that finalizes the update of ASC 
payment rates for the following calendar year, we will--
    + Provide a list of determinations made as a result of our review 
of all requests and public comments; and
    + Publish the deadline for submitting requests for review in the 
following calendar year.
    We note that we did not receive any review requests in response to 
the specific NTIOL April 28, 2006 notice (71 FR 25176) soliciting CY 
2006 requests for review of the appropriateness of the payment amount 
for particular NTIOLs furnished in ASCs.
    Comment: Most commenters supported in principle our proposal to 
incorporate NTIOL requests and approvals within the annual ASC notice 
and comment rulemaking cycle to promote greater coordination and 
efficiency. However, several commenters urged CMS to review NTIOLs on a 
quarterly rather than an annual basis. These commenters expressed 
concern about delays in beneficiary access to NTIOLs that could be 
avoided by quarterly reviews, which, the commenters noted, would also 
be more consistent with the CMS review cycle for OPPS pass-through 
device categories and new technology services. One commenter urged 
quarterly reviews so that lenses that belong to an active NTIOL class 
would not be competitively disadvantaged by having to wait for months 
or nearly a year to be recognized. Another commenter

[[Page 68177]]

recommended a 60-day comment period following issuance of the list of 
requests for NTIOL status rather than the 30-day comment period that we 
proposed.
    Response: We appreciate the commenters' support for our proposal to 
coordinate the public notice and comment process regarding requests to 
establish new NTIOL classes with the update of ASC payment rates. We 
understand and share the commenters' concerns about facilitating 
beneficiary access to technology with demonstrated clinical improvement 
over existing technology. However, section 141(b)(3) of the Social 
Security Act Amendments of 1994 (SSAA 1994), Public Law 103-432, 
requires us both to implement the payment adjustment for new classes of 
NTIOLs through notice and comment rulemaking in the Federal Register 
and to provide for a 30-day comment period on the lenses that are the 
subjects of the requests contained in the notice. We are not bound by 
the same prescriptive statutory requirements with regard to approval of 
applications for pass-through and new technology status under the OPPS, 
which is why we are able to implement updates of those provisions as 
part of the quarterly updates of the OPPS OCE and PRICER.
    However, we have issued a guidance document entitled ``Revised 
Process for Recognizing Intraocular Lenses Furnished by Ambulatory 
Surgery Centers (ASCs) as Belonging to an Active Subset of New 
Technology Intraocular Lenses (NTIOLs).'' This guidance document can be 
accessed on the CMS Web site at: http://www.cms.hhs.gov/ASCPayment/05_NTIOLs.asp.
    The guidance document provides details regarding requests for 
recognition of IOLs as belonging to an existing, active NTIOL category 
or subset, the review process, and information required for a request 
to review. Currently, there is one active NTIOL subset whose defining 
characteristic is the reduction of spherical aberration. CMS accepts 
requests throughout the year to review the appropriateness of 
recognizing an IOL as a member of an active subset of NTIOLs. That is, 
review of candidate lenses for an existing, active NTIOL subset is 
ongoing and not limited to the annual review process that applies to 
new NTIOL classes. We ordinarily would complete the review of a request 
within 90 days of receipt, and upon completion of our review, we would 
notify the requestor of our determination and post on the CMS Web site 
notification of a lens newly approved for a payment adjustment as an 
NTIOL belonging to an active NTIOL class when furnished at an ASC.
    We believe that consolidating the request, review, and approval 
process for new classes of NTIOLs as part of the annual ASC payment 
update cycle and accepting and reviewing requests for addition to an 
active NTIOL class on an ongoing basis will result in more timely 
access to improved health technologies for Medicare beneficiaries. 
Accordingly, we are revising Sec.  416.185 to reflect the changes that 
we proposed to the current process for publishing separate Federal 
Register notices specific to NTIOLs.
c. Factors CMS Considers in Determining Whether an Adjustment of 
Payment for Insertion of a New Class of NTIOL Is Appropriate
    In determining whether a lens belongs to a new class of NTIOLs and 
whether the ASC payment amount for insertion of that lens in 
conjunction with cataract surgery is appropriate, we expect that the 
insertion of the candidate IOL would result in significantly improved 
clinical outcomes compared to currently available IOLs. In addition, to 
establish a new NTIOL class, the candidate lens must be distinguishable 
from lenses already approved as members of active or expired classes of 
NTIOLs that share a predominant characteristic associated with improved 
clinical outcomes that were identified for each class. We proposed to 
base our determinations on consideration of the following factors:
     The IOL must have been approved by the FDA and claims of 
specific clinical benefits and/or lens characteristics with established 
clinical relevance in comparison with currently available IOLs must 
have been approved by the FDA for use in labeling and advertising.
     The IOL is not described by an active or expired NTIOL 
class; that is, it does not share the predominant, class-defining 
characteristic associated with improved clinical outcomes with 
designated members of an active or expired NTIOL class.
     Evidence demonstrates that use of the IOL results in 
measurable, clinically meaningful, improved outcomes in comparison with 
use of currently available IOLs. According to the statute, and 
consistent with previous examples provided by CMS, superior outcomes 
that would be considered include the following:
    + Reduced risk of intraoperative or postoperative complication or 
trauma;
    + Accelerated postoperative recovery;
    + Reduced induced astigmatism;
    + Improved postoperative visual acuity;
    + More stable postoperative vision;
    + Other comparable clinical advantages, such as--
    ++ Reduced dependence on other eyewear (for example, spectacles, 
contact lenses, and reading glasses)
    ++ Decreased rate of subsequent diagnostic or therapeutic 
interventions, such as the need for YAG laser treatment.
    ++ Decreased incidence of subsequent IOL exchange.
    ++ Decreased blurred vision, glare, other quantifiable symptom or 
vision deficiency.
    In order to assess the clinical performance of a candidate IOL to 
establish a new NTIOL class, outcomes from use of the candidate lens 
would be compared with outcomes of use of currently available IOLs. Due 
to the rapid evolution of medical technology, we expect that the 
baseline of currently available IOLs for comparison would change from 
year to year.
    Comment: Most commenters expressed general agreement with the 
criteria that we proposed as the factors we would consider in 
determining whether an adjustment of payment is appropriate for 
insertion of a new class of NTIOL. One commenter suggested amending 
Sec.  416.195(a)(4) to make it clear that the list of superior outcomes 
are examples and not an all-inclusive list.
    Response: We appreciate the commenter's concern that we not be 
overly prescriptive in what constitutes ``superior outcomes.'' However, 
we believe that Sec.  416.195(a)(4)(vi), ``Other comparable clinical 
advantages,'' has the same effect as the revision suggested by the 
commenter. In other words, the superior outcomes cited in Sec. Sec.  
416.195(a)(4)(i)-(v) are not all-inclusive, and extend to other 
comparable (but unspecified) clinical advantages. In the preamble of 
the proposed rule (71 FR 49633), we suggest several ``comparable 
clinical advantages'' for the purpose of illustration. These 
suggestions were intended to be examples but not an all-inclusive list.
    Comment: One commenter recommended removing ``Reduced dependence on 
other eyewear (for example, spectacles, contact lenses, and reading 
glasses)'' from the list of factors (71 FR 49633) because there should 
not be an NTIOL class for which the class-defining clinical advantage 
falls outside the scope of Medicare benefits.
    Response: We appreciate the comment. To avoid unnecessary 
confusion, we will remove ``reduced dependence on other eyewear'' from 
the list of illustrative improved clinical outcomes.

[[Page 68178]]

    Comment: The same commenter recommended that CMS clarify that when 
a requestor seeks to establish a new NTIOL category for a candidate IOL 
that bears the class-defining characteristic of an existing or expired 
NTIOL category but also offers an additional, new technological 
characteristic for which a new category is being sought that is 
distinguishable from the class-defining characteristic of an active or 
expired class, the lens should be eligible for consideration for NTIOL 
status as long as the characteristic and associated benefit of the 
active or expired class is not the basis of the request for a new 
class.
    Response: The commenter makes an excellent point. Revised Sec.  
416.195(a)(3) does not preclude from consideration as a member of a new 
class of NTIOL a lens that includes as one of its characteristics a 
class-defining characteristic associated with members of an active or 
expired class. Only if that shared characteristic were the predominant 
characteristic of the lens would it be precluded from approval as a new 
class of NTIOL. However, if the lens featured other characteristics, 
one or more of which predominated, that were clearly tied with improved 
clinical outcomes, the lens would not be disqualified from 
consideration as an NTIOL just because it also shared a characteristic 
with members of an active or expired class.
    Comment: One commenter recommended that if an IOL's label includes 
a claim of superiority, that CMS take that into account, but not 
require having the claim of superiority in FDA-approved labeling. The 
same commenter disagrees that FDA-approved labeling must include a 
statement of specific clinical benefits that would be the basis of an 
NTIOL request. A second commenter took the opposite position and 
commended CMS for requiring a copy of the labeling claims approved by 
the FDA for the IOL. The second commenter believed that this 
requirement (Sec.  416.195(a)(2)) is at the heart of an NTIOL 
application and that the FDA claims are of paramount importance in 
determining whether a lens is worthy of NTIOL status.
    Response: We appreciate both commenters points of view. However, we 
are not persuaded by the first commenter's arguments that FDA approval 
of claims made in the labeling for the IOL is of incidental 
significance. Therefore, we are not modifying Sec.  416.195(a)(2) as 
one of the factors that CMS will use to determine whether an IOL 
qualifies for a payment adjustment as a member of a new class of NTIOL 
when furnished at an ASC.
    In the proposed rule, we sought public comments on the desirability 
of further interpreting the phrase ``currently available lenses'' for 
purposes of comparison and specific approaches to providing such 
clarifications. We believe that further interpretation could be helpful 
to requestors seeking to provide the most relevant, authoritative 
evidence concerning the clinical benefits of their lenses in comparison 
with those currently available lenses and to us as we review the 
information provided in requests to establish new NTIOL classes. 
However, we also believe that any clarifications should incorporate our 
expectations for technological progression of the baseline comparison 
lenses over time as we make future annual determinations regarding the 
establishment of new NTIOL classes. Therefore, we believe that the 
public comments regarding practical and meaningful approaches to 
elaborating on the phrase ``currently available lenses'' would 
facilitate both requestors' submission of complete requests for review 
and appropriate determinations by CMS regarding new NTIOL classes to 
receive the ASC payment adjustment.
    Comment: Several commenters presented thoughtful, illuminating 
discussions of what might constitute the ``currently available lenses'' 
with which a candidate NTIOL would be compared. A couple of commenters 
suggested establishing a threshold of sales in the market to delineate 
currently available lenses. Other suggestions for ascertaining 
benchmark lenses included solicitation of comments from the ophthalmic 
medical community and IOL industry, and consideration of whether the 
class-defining characteristic of IOLs in an active or expired NTIOL 
class has become a medically-accepted baseline technology upon which 
future technologies will be added. One commenter suggested that the 
best approach to addressing the questions we posed in the proposed rule 
would be through a Town Hall meeting or other forum that would bring 
stakeholders and CMS staff together to further deliberate on the 
process of how to determine whether a lens qualifies for NTIOL status 
and the appropriateness of a payment adjustment for such lenses. Most 
commenters who addressed this issue recommended that CMS not attempt to 
define ``currently available lenses'' with too much specificity. These 
commenters stressed that it was important for CMS to maintain 
sufficient flexibility to account for evolving IOL standards and to 
allow a variety of appropriate lenses to serve as relevant benchmarks. 
One commenter noted that while foldable spherical monofocal IOLs 
represent the current state-of-the-art against which candidate NTIOLs 
ought to be compared at this time, future advances would create new 
standards and require flexibility on the part of CMS. Another commenter 
asserted that, in general, the next IOL technological advancement 
worthy of NTIOL status should build upon the state of technology that 
is current at the time. The same commenter further recommended that 
CMS, in addition to being flexible, consider each request for NTIOL 
review on an individual, case-by-case basis.
    Response: We appreciate commenters taking the time to formulate and 
communicate their views regarding the notion of ``currently available 
lenses.'' A number of thought-provoking suggestions were advanced. We 
agree with commenters that flexibility is critical, and that too much 
specificity would quickly become outdated by advancing technology. The 
commenters have presented a number of options for establishing baseline 
technology that we will carefully consider and evaluate during the 
course of future review of NTIOL applications. We look forward to 
continuing to work with stakeholders to ensure that our criteria and 
the NTIOL process generally are reasonable, are supportive of ongoing 
development of new IOL technology, and are geared to improved clinical 
outcomes for Medicare beneficiaries.
    In summary, after carefully considering the comments we received 
regarding the criteria we proposed as factors to be considered to 
determine whether an IOL qualifies for a payment adjustment as a member 
of a new class of NTIOL when furnished at an ASC, we are adopting as 
final, without modification, our proposed revision of Sec.  416.195.
d. Revision of Content of a Request To Review
    To enable us to make a determination that the criteria for a 
payment adjustment for a new NTIOL class are met, we proposed to 
require that a request include certain specific information, which is 
listed below. We made this proposal to revise the content of a request, 
which is currently set forth in Sec.  416.195(a), on the basis of our 
experience in evaluating applications for OPPS pass-through status for 
new device categories over the past 6 years. We have found that the 
additional information allows our medical advisors to complete a more 
comprehensive evaluation, which would ensure that a payment adjustment 
is appropriate. We

[[Page 68179]]

also have found that such information must be updated in a timely 
manner to ensure its relevancy to advancing technologies. Therefore, we 
also proposed to post the information that we require on the CMS Web 
site at: http://www.cms.hhs.gov/center/asc/asp to provide quick and 
easy access for updating rather than codifying the items required in 
the application.
    In addition, we proposed to require a separate request for each 
NTIOL for which a payment review as member of a new class is sought. We 
also proposed to consider a request that does not include all of the 
following information as incomplete and we proposed not to accept an 
incomplete request for review until all information is furnished. We 
proposed to require the following information:
     Proposed name or description of a new class of NTIOLs.
     Trade/brand name, manufacturer, and model number of the 
IOL for which the request to establish a new NTIOL class is being made. 
(Applications must include the name and description of at least one 
marketed IOL that would be placed in the proposed new NTIOL class.)
     A list of all active or expired NTIOL classes that 
describe similar IOLs. For each active or expired class, provide a 
detailed explanation as to why that class would not describe the 
candidate IOL.
     Detailed description of the FDA approved clinical 
indications for the candidate IOL.
     Description of the IOL--
    + What is it? Provide a complete physical description of the IOL, 
including its components, for example, its composition; coating or 
covering; haptics; material; and construction.
    + What does it do?
    + How is it used?
    + What makes it different from other currently available IOLs?
    + What makes it superior to other currently available IOLs used for 
similar indications?
    + What are its clinical characteristics, for example, is it used 
for treatment of specific pathology; what is its life span; what are 
the complications associated with its use; and for what patient 
populations is it intended?
    + Submit relevant booklets, pamphlets, brochures, product 
catalogues, price lists, and/or package inserts that further describe 
and illuminate the nature of the IOL.
     If the candidate IOL replaces or improves upon an existing 
IOL, identify the trade/brand name and model of the existing IOL(s).
     Full discussion of the clinically meaningful, improved 
outcomes that result from use of the candidate IOL compared to use of 
other currently available IOLs. This discussion must include evidence 
to demonstrate that use of the IOL results in measurable, clinically 
significant improvement over currently available IOLs in one or more of 
the following areas:
    + Reduced risk of intraoperative or postoperative complication or 
trauma.
    + Accelerated postoperative recovery.
    + Reduced induced astigmatism.
    + Improved postoperative visual acuity;
    + More stable postoperative vision.
    + Other comparable clinical advantages, such as--
    ++ Reduced dependence on other eyewear (for example, spectacles, 
contact lenses, and reading glasses);
    ++ Decreased rate of subsequent diagnostic or therapeutic 
interventions, such as the need for YAG laser treatment;
    ++ Decreased incidence of subsequent IOL exchange; and
    ++ Decreased blurred vision, glare or other quantifiable symptom or 
vision deficiency.
     Provide the following information for the IOL(s) for which 
a new class is proposed:
    + Dates the candidate IOL was first marketed, reporting inside the 
United States and outside the United States separately.
    + Dates of sale of the first unit of the IOL, reporting inside the 
United States and outside the United States separately.
    + Number of IOLs that have been sold up to the date of the 
application.
    + A copy of the FDA's original approval notification.
     A copy of the labeling claims approved by the FDA for the 
IOL, indicating its clinical advantages and/or the lens characteristics 
with clinical relevance.
     A copy of the FDA's summary of the IOL's safety and 
effectiveness.
     Reports of modifications made after the original FDA 
approval.
    We stated in the proposed rule that we strongly encourage and may 
give greater consideration for the submission of published, peer-
reviewed literature and other materials that demonstrate substantial 
clinical improvement with use of the candidate IOL over use of 
currently available IOLs.
    In our proposed Sec.  416.190(d), we provided that, in order for 
CMS to invoke the protection allowed under Exemption 4 of the Freedom 
of Information Act (5 U.S.C. 552(b)(4)) and, with respect to trade 
secrets, the Trade Secrets Act (18 U.S.C. 1905), the requestor must 
clearly identify all information that is to be characterized as 
confidential.
    Comment: Several commenters objected to our proposal to post on the 
CMS Web site the information required in a request for review of a 
potential new class of NTIOL rather than codifying it. Several 
commenters expressed concern that lags in Web site updates may 
compromise an NTIOL sponsor's ability to design and implement requisite 
studies and generate data that will adequately support timely 
consideration and approval of an application. Another commenter urged 
that there be sufficient stability in the requirements so that a 
manufacturer does not invest several months or years in conducting a 
comparative clinical study, only to learn when it is ready to submit an 
NTIOL request that the criteria have changed. Several commenters 
suggested that requestors have the opportunity to meet with CMS to 
discuss the study design and application processes to ensure that the 
agency's demands for documentation of an IOL's benefits are fully 
understood by applicants and are met upon submission of the 
application.
    Response: We have received hundreds of applications for pass-
through payment for devices and drugs and payment for new technology 
services under the OPPS using a format and process similar to that 
proposed for NTIOLs. The format for pass-through and new technology 
requests under the OPPS as well as the details of the application 
process are posted on the CMS Web site, but they are not codified. As a 
matter of policy and practice, we are available to meet with anyone 
with an interest in developing a request for consideration of a new 
class of NTIOLs at any time, to ensure that our requirements are clear 
and thoroughly understood by the requestor, and also to give CMS an 
opportunity to preview a potential applicant for NTIOL status. The 
application process is an interactive collaboration between CMS and the 
requestor that continues until CMS has all of the information it needs 
to be able to make a determination.
    We are concerned that commenters may also be confusing the factors 
that we are implementing in revised Sec.  416.195, which are the 
criteria that CMS will consider to determine whether an IOL qualifies 
for a payment adjustment as a member of a new NTIOL class, with the 
items of information listed in the proposed rule in section XVII.E.2.d 
of the preamble, which comprise a list of the information that CMS 
needs in order to determine whether a lens meets the criteria in Sec.  
416.195.

[[Page 68180]]

    Finally, we are confused about commenters' apprehension regarding 
the potential for research studies being undermined in some manner if 
the information required for a request for NTIOL eligibility is not 
codified. The information required for a request for NTIOL eligibility 
is mostly descriptive and explanatory; it is not information required 
for a research study.
    Comment: One commenter recommended that any information concerning 
NTIOLs be made available for public review and comment. Another 
commenter contended that the APA requires that the content requirements 
for an NTIOL payment request be subject to notice and comment 
rulemaking and subsequently published in the Code of Federal 
Regulations and also that any future revisions be subject to notice and 
comment rulemaking.
    Response: We disagree with the commenters' contention that the 
points of information we proposed to require in a request to review a 
lens must be enumerated in the Code of Federal Regulations. We note 
that the information listed in current Sec.  416.195(a)(1) through (5) 
is included in the list of information in section XVII.E.2.d. of the 
proposed rule (71 FR 49634). The additional points of information that 
we proposed to require in section XVII.E.2.d. of the preamble are 
simply an explicit itemization of ``other information that CMS finds 
necessary for identification of the IOL'' (see Sec.  416.195(a)(6) of 
the current regulations). Instead of requiring requestors to use a pre-
printed, prescribed application form, we simply list the individual 
items of information that have to be supplied, which we accept in 
whatever format the requestor finds most convenient. Moreover, the CY 
2007 OPPS proposed rule has provided an opportunity for public comment 
on the information required in a request for NTIOL consideration. The 
few comments that we received are addressed below. The criteria for 
determining whether or not a lens qualifies as belonging to a new class 
of NTIOL are what require public comment, not the list of information 
needed to apply the criteria.
    Comment: One commenter believed that the mere fact that scientific 
evidence has been published in a peer-reviewed journal should not 
impact whether CMS determines the evidence is credible. The commenter 
further believed that a study that has been accepted or published in a 
peer-reviewed journal should not be given greater weight simply because 
it has been published.
    Response: We agree with the commenter's assertion that there are a 
variety of forms in which credible evidence can be presented, in 
addition to publication in a peer-reviewed journal. We encourage the 
submission of all credible evidence, published or not. However, we 
believe that published, peer-reviewed literature has particular value 
in that it is the product of a rigorous process of thorough scrutiny 
and standards that are acknowledged and recognized throughout the 
academic and scientific community.
    For reasons stated above, as we proposed, we are revising Sec.  
416.190 to reflect the specified changes to the content of a request 
for payment review of an IOL, to clarify when a request can be 
submitted and who may submit, and to also clarify the process for 
maintaining confidentiality of information included in a request. As 
stated earlier, we are not incorporating the list of information 
required with each request in the regulations, but are posting it on 
the CMS Web site to ensure that such information is updated in a timely 
manner and relevant to advancing IOL technologies. We are revising 
Sec.  416.190 to require that the content of each request for an IOL 
review must include all information as specified on the CMS Web site 
for the request to be considered complete.
e. Notice of CMS Determination
    In the CY 2007 OPPS proposed rule, we proposed three possible 
outcomes from review of a request for determination of a new NTIOL 
class. As appropriate, for each completed request for a candidate IOL 
that is received by the established deadline, one of the following 
determinations would be announced annually in the final rule updating 
the ASC payment rates for the next calendar year:
     The request for a payment adjustment is approved for the 
IOL for 5 full years as a member of a new NTIOL class described by a 
new code.
     The request for a payment adjustment is approved for the 
IOL for the balance of time remaining as a member of an active NTIOL 
class.
     The request for a payment adjustment is not approved.
    We also proposed to summarize briefly in the ASC final rule the 
evidence that was reviewed, the public comments, and the basis for our 
determination. When a new NTIOL class is established, we proposed to 
identify the predominant characteristic of NTIOLs in that class that 
sets them apart from other IOLs (including those previously approved as 
members of other expired or active NTIOL classes) and is associated 
with improved clinical outcomes. The date of implementation of a 
payment adjustment in the case of approval of an IOL as a member of a 
new NTIOL class would be set prospectively as of 30 days after 
publication of the ASC payment update final rule, consistent with the 
statutory requirement. The date of implementation of a payment 
adjustment in the case of approval of a lens as a member of an active 
NTIOL class would be set prospectively as of the publication date of 
the ASC payment update final rule.
    We received no comments on these proposals. Therefore, we are 
making final, without modification, the process and timelines that we 
proposed.
f. Payment Adjustment
    The current payment adjustment for a 5-year period from the 
implementation date of a new NTIOL class is $50. In the CY 2007 OPPS 
proposed rule, we did not propose to revise this payment adjustment for 
CY 2007.
    For CY 2007, we proposed to revise Sec.  416.200(a) through (c) to 
clarify how the IOL payment adjustment would be made and how a NTIOL 
would be paid after expiration of the payment adjustment. We also 
proposed minor editorial changes to Sec.  416.200(d).
    Comment: Several commenters expressed concern that the $50 payment 
adjustment for a new NTIOL class is inadequate, has not been adjusted 
for inflation since it was initially implemented, and is out of step 
with the rising costs of innovative research. One commenter objected to 
a flat $50 adjustment for all NTIOLs on the grounds that research, 
development and production costs vary from lens to lens. Several 
commenters recommended that manufacturers be given the opportunity to 
present a request, supported by appropriate documentation, for a higher 
payment adjustment for NTIOLs for which it is warranted.
    Response: In January 2008, as discussed elsewhere in this final 
rule with comment period, we plan to implement a significantly revised 
payment system for ASC facility services, which will affect payment for 
all ASC services, including payment for IOLs and their insertion and 
payment for cataract surgery. Only after we have implemented the 
revised ASC payment system in CY 2008 will we be able to evaluate 
whether or not the ASC facility fee established for cataract surgery 
with IOL insertion is appropriate when a lens determined to be an NTIOL 
is furnished. Therefore, we are retaining for now the current $50 
payment adjustment for a new NTIOL class. In addition, we are

[[Page 68181]]

adopting as final without modification our proposal to revise Sec.  
416.200(a) through (c) to clarify how the IOL payment adjustment will 
be made and how a NTIOL will be paid after expiration of the payment 
adjustment; and to make minor editorial changes to Sec.  416.200(d).
    In summary, after careful consideration of the public comments we 
received timely regarding our proposed changes, we are adopting as 
final without modification, with the exception of a few technical 
edits, the provisions of proposed new Subpart G under Part 416 to 
codify the rules governing the ASC payment adjustment for NTIOLs.

G. Announcement of CY 2007 Deadline for Submitting Requests for CMS 
Review of Appropriateness of ASC Payment for Insertion Following 
Cataract Surgery of an NTIOL

    In accordance with Sec.  416.185(a) of our regulations, as revised 
by this final rule with comment period, CMS announces that, in order to 
be considered for payment effective January 1, 2008, requests for a 
review of an application for a new class of new technology IOLs must be 
received at CMS by COB, April 1, 2007. Send requests to: ASC/NTIOL, 
Division of Outpatient Care, Mailstop C4-05-17, Centers for Medicare 
and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-
1850.
    To be considered, requests for NTIOL reviews must include the 
information posted on the CMS Web site at http://cms.hhs.gov/ASCPayment/05_NTIOLs.asp#TopOfPage.

XVIII. Medicare Contracting Reform Mandate

A. Background

    Section 911 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA), Public Law 108-173, amended Title 
XVIII of the Act to add section 1874A, Contracts with Medicare 
Administrative Contractors (MACs). Section 1874A of the Act replaces 
the prior Medicare intermediary and carrier contracting authorities 
formerly found in sections 1816 and 1842 of the Act, respectively. This 
reform (commonly referred to as ``Medicare contracting reform'' for 
Medicare fee-for-service) is intended to improve Medicare's 
administrative services to beneficiaries and health care providers and 
to bring standard contracting principles to Medicare, such as 
competition and performance incentives, which the government has long 
applied to other Federal programs under the Federal Acquisition 
Regulation (FAR). For Department of Health and Human Services 
acquisitions, the FAR is supplemented by the Department of Health and 
Human Services Acquisition Regulation (HHSAR) at 48 CFR chapter 3. 
Using competitive procedures, CMS will replace its current claims 
payment contractors (intermediaries and carriers) with new contract 
entities, MACs. Section 911(d)(1)(C) of Public Law 108-173 requires 
that CMS compete and transition all Medicare claims processing 
workloads to MACs by October 1, 2011.
    In accordance with section 911(e) of Public Law 108-173, on or 
after October 1, 2005, any reference to an ``intermediary'' or 
``carrier'' in a regulation shall be deemed a reference to a MAC. The 
process of transition from intermediaries and carriers to MACs is not a 
single point-in-time occurrence, but rather necessarily happens over a 
multiyear period due to the size and nature of the claims workloads 
involved. Therefore, for the purposes of clarity, the term 
``intermediary'' is used throughout this final rule with comment period 
to describe a Medicare contractor, pursuant to the authority of section 
1816 of the Act, that has not yet transitioned to a MAC. In addition, 
for the purpose of clarity, the term ``carrier'' is used throughout 
this final rule with comment period to describe a Medicare contractor, 
pursuant to the authority of section 1842 of the Act, that has not yet 
transitioned to a MAC.

B. CMS' Vision for Medicare Fee-for-Service and Medicare Administrative 
Contractors (MAC)

    CMS' vision for the Medicare fee-for-service (FFS) program is that 
of a premier health plan that allows for comprehensive, quality care 
and world-class beneficiary and provider services. Achieving this 
vision requires substantial improvement of CMS' current FFS 
administrative structure. Further information on CMS' plans to improve 
Medicare FFS may be obtained through the Medicare Contracting Reform 
Web site: http://www.cms.hhs.gov/medicarereform/contractingreform/.
    As of November 1, 2006, there are 20 intermediaries and 18 carriers 
that process FFS claims. Intermediaries process claims for Medicare 
Parts A and B relating to services furnished by health care facilities, 
including hospitals and SNFs. Carriers process claims for Medicare Part 
B, in particular, for physician, laboratory, and other nonfacility 
services. Four intermediaries serve as regional home health 
intermediaries (RHHIs) and process Medicare claims for home health 
services and hospice services. (Section 1816 of the Act was amended in 
1977 to allow the Secretary to designate regional or national 
intermediaries, which we refer to as RHHIs, to process claims for home 
health services. We have designated these RHHIs to serve both the home 
health agency (HHA) and the hospice provider communities.) Four Durable 
Medical Equipment Regional Carriers (DMERCs) process claims for durable 
medical equipment, prosthetics, and orthotics. For a complete listing 
of the current Medicare intermediaries and carriers, refer to the CMS 
Web site: http://www.cms.hhs.gov/contacts/incardir.asp.
    Although health care delivery in the United States has evolved with 
advances in modern technology, the contracting authorities relating to 
the Medicare FFS administrative structure did not substantially evolve 
between the enactment of the Medicare statute in 1965 and the enactment 
of Public Law 108-173.
    Prior to passage of Public Law 108-173, intermediary and carrier 
acquisition authorities did not require full and open competition or 
unified processing of Medicare Part A and Part B claims. Medicare 
contracting was significantly hampered by absence of competition and 
cumbersome termination procedures. In an effort to achieve Congress' 
goal of a more efficient and effective Medicare operation, CMS 
developed a plan for most current Medicare Part A and Part B 
intermediary and carrier responsibilities to be integrated into a 
single contract entity to be administered by a single contractor in 
each area of the country. These new MACs will handle claims processing 
and related activities traditionally performed by intermediaries and 
carriers.
    Under Medicare contracting reform, the MACs will perform all the 
core claims processing operations for both Medicare Part A and Part B. 
CMS will ensure that MACs focus on providing a high level of customer 
service to providers and beneficiaries. MACs will be the providers' 
primary contact with Medicare, and CMS will hold the MACs accountable 
for overall provider and beneficiary satisfaction and correct claims 
payment.
    With respect to financial management, as was required of 
intermediaries and carriers, MACs will promote the fiscal integrity of 
the program and be accountable stewards of the Medicare Trust Fund 
dollars. The MACs will be required to pay claims

[[Page 68182]]

timely, accurately, and in a reliable manner while promoting cost 
efficiency and the delivery of maximum value to the program.
    We recognize the potential for improving the efficiency and 
effectiveness of services to Medicare beneficiaries and providers 
through the Medicare contracting reform provisions contained in section 
1874A of the Act. Through our implementation of these provisions, we 
expect to realize significant performance improvements. The future 
environment is designed to generate substantial savings both from an 
administrative and programmatic standpoint and will safeguard CMS' 
mission.

C. Provider Nomination and the Former Medicare Acquisition Authorities

    As originally enacted in 1965 and until the enactment of Public Law 
108-173, section 1816 of the Act afforded groups or associations and 
individual providers of services (as defined at section 1861(a) of the 
Act) the right to nominate (appoint) their intermediary. The 
intermediary agreements were governed by Medicare laws that diverge 
from the FAR in a number of important respects. Prior to Public Law 
108-173, section 1816 of the Act precluded the Medicare program from 
competing intermediary functions on a full and open basis. Rather, 
institutional providers of services, such as hospitals and nursing 
facilities, nominated a particular intermediary to process and pay 
their Medicare Part A claims.
    In a significant historical development that took place shortly 
after Medicare's enactment in 1965, the American Hospital Association 
and other provider trade associations nominated the Blue Cross 
Association (BCA) to serve as the intermediary for their membership. 
The BCA merged with the Blue Shield Association in the 1970s to form 
today's Blue Cross and Blue Shield Association (BCBSA.) CMS and the 
BCBSA then entered into a prime contract, which continues to currently 
exist through the annual renewal process. In turn, the BCBSA 
subcontracted most operational intermediary functions to its member 
plans. The BCBSA assigned the majority of the nation's hospitals to its 
local Blue Cross plans. Some providers of services nominated commercial 
insurers to serve as their intermediaries.
    Most recently, section 911(b) of Public Law 108-173 amended section 
1816 of the Act to remove the provider nomination authority. The 
section has been renamed: ``Provisions Relating to the Administration 
of Part A.'' Section 1816(a) of the Act, which authorized providers to 
select a contractor to perform claims payment and audit functions, has 
been amended. It now contains one sentence mandating the use of 
contracts with MACs to administer section 1816 of the Act. Sections 
1816(e), (f), and (g) of the Act, which authorized the Secretary to 
develop standards, criteria, and procedures for the assignment of 
providers to intermediaries and to reassign providers periodically, 
have been repealed.
    Section 911(d) of Public Law 108-173 permits the Secretary to 
transition the current intermediary and carrier functions to the MACs. 
More information about CMS' plans to implement Medicare contracting 
reform, including the Report to the Congress on this subject, can be 
obtained at the CMS Web site: http://www.cms.hhs.gov/medicarereform/contractingreform/. MACs will perform all core 
claims processing operations for both Medicare Part A and Part B. The 
Part A and Part B MACs will operate in distinct, nonoverlapping 
geographic jurisdictions, which will form the basis of the Medicare 
claims processing operations. A transitional period runs between 
October 1, 2005, and October 1, 2011. During this period, any existing 
intermediary and carrier contracts could be maintained until replaced 
by a MAC contract. The statute requires that all intermediary and 
carrier contracts are to be competed and awarded as MAC contracts by 
October 1, 2011.

D. Summary of Changes Made to Section 1816 of the Act

    Substantial changes to section 1816 of the Act that were required 
by sections 911(b) and 911(c) of Public Law 108-173 took effect on 
October 1, 2005. The changes that we proposed and are finalizing in 
this final rule with comment period to the regulations under 42 CFR 
Part 421, Subpart B (discussed under section XVIII.E. of this preamble) 
are intended to conform the regulations to these statutory changes.
    Prior to the statutory developments directed by Public Law 108-173, 
section 1816 of the Act provided the foundation acquisition authority 
for agreements between CMS, acting for the Secretary, and 
intermediaries, for the purpose of administering benefits under 
Medicare Part A and making payments to providers of services.
    In particular, section 1816(a) of the Act formerly gave groups and 
associations of providers of services (which, under section 1861(u) of 
the Act, includes hospitals, CAHs, SNFs, CORFs, HHAs, hospices, and, 
for the purposes of sections 1814(g) and 1835(e) of the Act, funds) the 
power to nominate their servicing intermediary to determine and make 
Medicare payments to their members. Under this provision, an 
intermediary could be a ``national, state, or other public or private 
agency or organization.'' As previously stated, under this provision, 
the American Hospital Association nominated the national Blue Cross 
Association to serve as the prime Medicare intermediary for its 
membership in 1965, an arrangement that will continue to exist until 
full implementation of MACs.
    Moreover, prior to the enactment of Public Law 108-173, section 
1816(d) of the Act allowed individual providers and groups of providers 
to--
     Part with their group or association and nominate another 
entity to serve as their intermediary; and
     Withdraw its/their nomination from an intermediary, and 
obtain services from another intermediary that had an agreement with 
the Secretary.
    Finally, section 1816(e) of the Act, as it formerly read, specified 
the substantial procedural requirements to be followed by the Secretary 
in the event that the Secretary desired to assign or reassign 
individual providers of services to any intermediary other than the 
nominated entity. This provision also gave limited authority to the 
Secretary to designate a regional or national intermediary for a 
particular ``class'' of providers of services. However, this authority 
was subject to substantial procedural requirements. Among these 
procedural requirements were:
     The Secretary had to promulgate standards, criteria, and 
procedures for evaluating the performance of intermediaries under 
section 1816(f) of the Act;
     The Secretary had to make a finding, after applying such 
standards, criteria, and procedures, that the reassignment of the 
individual provider and/or the designation of the regional or national 
intermediary would result in more efficient and effective 
administration of the Medicare program;
     The Secretary had to provide a full explanation of the 
reasons for determining that the intermediary change would result in 
more efficient and effective administration; and
     Affected agencies and organizations were given the right 
to a hearing, and any determinations of the Secretary on nominations 
and provider assignments were subject to judicial review.
    In the former sections 1816(e)(4) and 1816(e)(5) of the Act, the 
Secretary was given authority to establish regional intermediaries with 
respect to HHAs and hospice providers, although certain

[[Page 68183]]

procedural requirements still had to be met.
    In summary, while, under section 1816 of the Act, the Secretary was 
not required to accept all Medicare intermediary nominations, the 
Secretary had no independent authority to contract with any entity for 
Medicare intermediary services outside the nomination process. 
Moreover, while providers of services were given the opportunity to 
seek a reassignment to a new intermediary, the Secretary could not 
assign or reassign individual providers or classes of providers unless 
substantial procedural requirements were followed.
    The existing Medicare regulations under 42 CFR Part 421, 
particularly those within Subparts A and B, were substantially shaped 
by this statutory framework relating to provider nominations and the 
assignment or reassignment of providers of services to intermediaries. 
In particular, the following regulatory provisions have their basis in 
the statutory provisions of sections 1816(a), (d), and (e) of the Act 
(all are located within 42 CFR Part 421):
     Sec.  421.1(c), which discusses criteria to be used in 
assigning and reassigning providers;
     Sec.  421.3, which provides exceptions to definitions to 
accommodate the designation of regional intermediaries for HHAs and 
intermediaries for hospices;
     Sec.  421.103, which identifies options available to 
providers for receiving Medicare payments;
     Sec.  421.104, which provides the procedural framework 
governing the administration of provider nominations for 
intermediaries;
     Sec.  421.105, which obligates CMS to provide notice as to 
its action on nominations;
     Sec.  421.106, which specifies the process to be used by a 
provider desiring a change of intermediary;
     Sec.  421.112, which provides the considerations to be 
taken into account by CMS when, among other things, it desires to 
assign or reassign a provider to an intermediary or designate a 
regional or national intermediary for a class of providers;
     Sec.  421.114, which governs the assignment or 
reassignment of individual providers;
     Sec.  421.116, which specifies the requirements for 
designating national or regional intermediaries consistent with 
sections 1816(e)(1) through (e)(3) of the Act; and
     Sec.  421.117, which specifies the parameters for 
assigning HHAs and hospice providers to regional intermediaries 
consistent with sections 1816(e)(4) and (e)(5) of the Act.
    In addition to the provisions discussed above that relate to 
provider nominations, prior to the enactment of Public Law 108-173, 
section 1816 of the Act also contained other provisions governing 
agreements with Medicare intermediaries that were not consistent with 
the mainstream of Federal acquisition and procurement authorities, as 
this mainstream is reflected in the FAR. For instance--
     Section 1816(b) of the Act contains provisions that 
limited payment under all intermediary agreements to a cost-
reimbursement basis only;
     Section 1816(f) of the Act required the Secretary to 
publish the performance criteria and standards for intermediary 
agreements in the Federal Register, and specified requirements relating 
to the application of such criteria and standards; and
     Section 1816(g) afforded intermediaries the right to 
terminate their agreements with CMS, but limited the right of the 
Secretary to terminate an agreement; in particular, no provision was 
made for the normal right of the government to terminate for 
convenience.
    In section 911(b) of Public Law 108-173, Congress reiterated the 
requirement that CMS begin to move beyond the legacy nomination-based 
intermediary agreements during FY 2006. This was done by repealing 
outright or substantially modifying many of the provisions of section 
1816 of the Act, effective October 1, 2005. In particular, section 
911(b) of Public Law 108-173--
     Repealed the prior language of section 1816(a) of the Act, 
including the basic provider nomination provision, and replaced it with 
a statement indicating that Medicare Part A administrative functions 
would be contracted through section 1874A of the Act;
     Repealed section 1816(b) of the Act in full, including its 
provisions limiting payment to cost reimbursement;
     Repealed the contract-related provisions of section 
1816(c) of the Act;
     Repealed sections 1816(d), (e), (f), (g), (h), (i), and 
(l) of the Act; and
     Made conforming changes to sections 1816(c), (j), and (k) 
of the Act.
    With these changes, section 1816 of the Act is no longer an 
acquisition authority, and there is no vestige of the former provider 
nomination provisions or the partial exceptions to those provisions 
relating to HHAs and hospice providers.
    While section 911(d)(1)(B) of Public Law 108-173 allows the 
Secretary to continue intermediary and carrier contracts in effect 
prior to October 1, 2005, under their terms and conditions until 
October 1, 2011, there was no similar extension for existing nomination 
arrangements. Section 911(d)(2)(A) of Public Law 108-173 provides the 
Secretary with authority to enter into intermediary agreements outside 
of the provider nomination process starting with the date of enactment 
of Public Law 108-173 (December 8, 2003). Therefore, while Congress 
specified that the Secretary should submit a plan for implementing 
section 911 at the start of FY 2005, the Secretary was authorized to 
contract outside of the section 1816 nomination provisions immediately 
and in advance of delivery of the report to Congress. This analysis 
requires that similar, conforming changes be made in our regulations as 
set forth in the proposed rule and as finalized in this final rule with 
comment period.

E. Provisions of the Proposed and Final Regulations

    As discussed under section XVIII.A. of this preamble, based on the 
authority provided in sections 1874A(a) through (d) of the Act, as 
established by section 911(a)(1) of Public Law 108-173, we are 
finalizing our proposed rules to establish regulations pertaining to 
MACs in a new Subpart E of 42 CFR Part 421. Moreover, based on the 
substantial changes to section 1816 of the Act, including the repeal of 
all of the section 1816 provisions relating to the ability of providers 
to nominate their servicing intermediary, as enacted by section 911(b) 
of Public Law 108-173, we also are making a number of changes to 
Subparts A and B of 42 CFR Part 421. In addition, we are changing the 
title of Part 421 from ``Intermediaries and Carriers'' to ``Medicare 
Contracting'' and making conforming revisions to Subpart B of Part 421.
    As discussed earlier, section 911(b) of Public Law 108-173 either 
repealed outright or substantially modified sections 1816(a), (b), (c), 
(d), (e), (f), (g), (h), (i), and (l) of the Act, and made clear that 
the acquisition authority for Part A claims processing would, after 
October 1, 2005, be found in section 1874A of the Act. Among all these 
changes, each of the former ``provider nomination'' provisions within 
section 1816 of the Act was repealed. In addition, section 911(d)(2)(A) 
of Public Law 108-173 gave the Secretary authority to disregard the 
provider nomination provisions in this contracting, even prior to 
October 1, 2005. In accordance with these statutory changes, we are 
finalizing our proposal to substantially modify or delete Sec. Sec.  
421.1(c), 421.3, 421.103, 421.104,

[[Page 68184]]

421.105, 421.106, 421.112, 421.114, 421.116, and 421.117 of the 
regulations.
    As discussed earlier, the amendment to title XVIII of the Act (to 
allow for the new section 1874A: ``Contracts with Medicare 
Administrative Contractors'') requires CMS to contract with eligible 
entities to perform Medicare functions using the FAR. We are adding 
regulations pertaining to MAC contracts in a new subpart E (Medicare 
Administrative Contractors) under Part 421 as follows: Sec.  421.400 
(Basis and scope), Sec.  421.401 (Definitions), and Sec.  421.404 
(Assignment of providers and suppliers to MACs).
1. Definitions
    As we proposed under proposed Sec.  421.401, in this final rule 
with comment period, we are defining a ``Medicare administrative 
contractor (MAC)'' as an agency, organization, or other person with a 
contract to perform any or all of the functions set forth under section 
1874A of the Act. With respect to the performance of a particular 
function in relation to an individual entitled to benefits under 
Medicare Part A or enrolled under Medicare Part B, or both, or a 
specific provider of services or supplier (or class of such providers 
of services or suppliers), we are defining an ``appropriate MAC'' as a 
MAC that has a contract to perform a Medicare administrative function 
in relation to a particular individual, provider of services, or 
supplier, or a particular class of providers.
2. Assignment of Providers and Suppliers to MACs
    As we proposed, in this final rule with comment period, we are 
establishing a new Sec.  421.404 to incorporate the rules governing the 
processing of claims submitted by providers and suppliers that enroll 
with and receive Medicare payment and other Medicare services. As a 
general rule, Medicare providers and suppliers will be assigned to the 
MAC that is contracted to administer the types of services (benefits) 
billed by the provider or supplier within the geographic locale in 
which the provider or supplier is physically located or furnishes 
health care services, respectively. One significant exception to this 
general rule pertains to suppliers of durable medical equipment, 
prosthetics, orthotics, and supplies. These suppliers will bill the MAC 
covering the area where the beneficiary resides--a continuation of 
existing policy.
    In the past, under the provider nomination provisions that were 
repealed by section 911 of Public Law 108-173, CMS had considered (and 
occasionally approved) requests from certain classes of institutional 
providers covered by these section 1816 provisions, primarily, 
hospitals, SNFs, and CAHs, to bill an intermediary other than the one 
servicing providers in the geographic locale of the provider. The 
process and criteria for making these determinations are set forth in 
detail in the existing regulations under 42 CFR Part 421, Subpart B 
(which we are removing in accordance with the changes effectuated by 
section 911(b) of Public Law 108-173).
    In particular, not automatically but on a fairly frequent basis, 
CMS approved requests from large multi-State groups of such providers 
under common ownership and control, called ``chain providers,'' to bill 
a single intermediary on behalf of all the individual providers in the 
chain through the headquarters office, or ``home office,'' of the chain 
provider. These chain providers were granted ``single intermediary'' 
status.
    The premise behind granting privileges to bill a single 
intermediary to such large multi-State chain providers was that this 
might reduce administrative billing expenses for the chain and reduce 
the administrative expenses of the Medicare program. In particular, 
assigning a large multi-State chain provider to a single intermediary 
facilitated the Medicare cost report audit and reimbursement functions, 
because findings with respect to the cost report of the chain's home 
office could affect the individual provider's cost report. Otherwise, 
these audit and reimbursement issues would need to be coordinated among 
multiple intermediaries.
    In addition to applying the relevant regulatory requirements in 42 
CFR Part 421, Subpart B in our review of chain provider requests for 
single intermediary status, we applied additional criteria to focus our 
analysis and to ensure that the exception to our normal practice of 
assigning providers to their ``local'' intermediary was warranted. We 
advised the chain provider that it would have to demonstrate that 
having a single intermediary would be consistent with efficient and 
effective administration of the Medicare program, and that the 
intermediary would need to have sufficient capacity to effectively 
serve the chain (these elements were restatements of the regulatory 
criteria). In addition, we required the chain to meet the following 
requirements:
     Size--The provider chain had to be comprised of 10 
participating facilities or 500 certified beds, or 5 facilities or 300 
certified beds spread across 3 or more contiguous States.
     Central Controls--The provider chain had to demonstrate 
that it exercised central controls, assuring substantial uniformity in 
operating procedures, utilization controls, personnel administration, 
and fiscal operations among the individual providers.
    The administrative efficiencies gained by both the large multi-
State chain providers and the Medicare program by allowing single 
intermediary relationships to exist may not be as significant as they 
were formerly. Prior to the implementation of the Administration 
Simplification provisions of Part C of Title XI of the Act, the various 
intermediaries required providers to use somewhat divergent transaction 
and formatting standards in their electronic claims processing systems. 
A provider chain with centralized billing processes could make a good 
business case that it should be permitted to bill only one 
intermediary. Moreover, prior to the implementation of the many 
prospective payment systems required by the Balanced Budget Act of 1997 
and subsequent public laws, a greater percentage of Medicare program 
payments hinged on the Medicare cost report audit and reimbursement 
process. In such an environment, there was potential benefit to both a 
chain provider and the government to minimize coordination issues. 
Finally, the former Medicare environment involved many intermediaries, 
so there were naturally more geographic boundaries among contractors 
that a multi-State chain could cross.
    We understand the provisions of section 1874A of the Act and, more 
particularly, the revisions to section 1816 of the Act made by section 
911(b) of Public Law 108-173 to authorize the Secretary to assign all 
providers and suppliers, even the members of multi-State entities, to 
the geographically based MACs based on their physical location. This 
action is consistent with CMS' vision, as articulated in the 
Secretary's Report to Congress on Medicare Contracting, of establishing 
a claims processing environment where most Medicare Part A and Part B 
claims involving a particular beneficiary are administered by the same 
contractor.
    However, as indicated in that Report (page V-4), we recognize that 
there may still be some legitimate business value to allowing large 
multi-State chains of providers that formerly were able to nominate 
their intermediary to bill on a consolidated basis to one MAC. While 
section 911(d)(1)(C) of Public Law 108-

[[Page 68185]]

173 abolished the former provider nomination framework, we believe that 
allowing the practice of consolidated billing by large chains is within 
the discretion of the Secretary under section 911 of Public Law 108-
173. Accordingly, in this final rule with comment period, we are 
finalizing our proposal under Sec.  421.404 that--
     Providers (as defined in 42 CFR 400.202) will generally be 
assigned to the MAC with claims processing jurisdiction over the 
geographic locale in which the provider is physically located.
     Large chain providers comprised of individual providers 
that were formerly permitted by CMS to ``nominate'' an intermediary, 
which we refer to as ``qualified chain providers,'' will be permitted 
to request opportunity to consolidate their Medicare billing activities 
to the MAC with jurisdiction over the geographic locale in which the 
chain's home office is located.
     Qualified chain providers that were formerly granted 
single intermediary status do not need to re-request such privileges on 
behalf of the entire chain.
     CMS may grant other exceptions to the general rule for 
assigning providers to MACs, but only based on a finding that such an 
exception will support the implementation of the MACs or if CMS deems 
the exception to be in the compelling interest of the Medicare program.
    We are incorporating a definition of ``qualified chain provider.'' 
The criteria that constitute the definition of a ``qualified chain 
provider'' mirror the elements that were historically applied. We 
believe these are appropriate criteria to employ in reviewing whether a 
chain provider should even be considered for consolidated billing. Less 
stringent criteria would clearly cut against the statutory mandate to 
establish MACs and end the provider nomination process. More stringent 
criteria might disrupt the operations of many entities that formerly 
were approved for single intermediary handling under the old criteria.
    Smaller chains of otherwise eligible providers (for example, 
hospitals, SNFs, and CAHs) might also desire consolidated billing, as 
well as other types of providers (for example, HHAs and hospices). In 
the latter case, the other types of providers (termed ``ineligible 
providers'' in this final rule with comment period) did not have the 
opportunity to request assignment to (nominate) a particular 
intermediary prior to October 1, 2005. In some cases, these other types 
of providers were assigned to regional intermediaries based on a nexus 
of statutory and administrative actions. In other cases, assignments 
were made through administrative action. In the case of smaller chains 
of otherwise eligible providers, we note that section 911(d)(1)(C) of 
Public Law 108-173 abolished the provider nomination framework and 
appears to us to anticipate the use of regional contractors.
    We believe that our establishment of MACs that, in most cases, will 
administer claims from multiple States will largely resolve the 
concerns these other providers may have. Under our approach, for 
instance, we believe that few chain providers will have to bill more 
than two MACs even if they fail to meet the tests for being a 
``qualified chain provider.''
    Finally, with respect to suppliers (as also defined in 42 CFR 
400.202 of our regulations), we are assigning suppliers (including 
physicians and nonphysician practitioners) to MACs based on the 
geographic jurisdiction in which they operate and furnish services. 
These requirements mirror the various Part B claims jurisdiction rules 
that have been in place. CMS may grant an exception to this policy only 
if CMS finds the exception will support the implementation of MACs or 
will serve some compelling interest of the Medicare program. However, 
we do incorporate the current special billing requirements relating to 
DMEPOS suppliers in Sec.  421.210 and Sec.  421.212.
    We indicated in the proposed rule that as we move forward to 
implement MAC contracting in keeping with the statutory mandate of 
section 911 of Public Law 108-173 and the Secretary's Report to 
Congress, we were inviting public comments on these specified issues, 
including our proposed definitions and criteria. (Once the MACs are 
initially implemented, we indicated that we may propose more stringent 
criteria for consolidated billing status, in keeping with the overall 
thrust of section 911 of Public Law 108-173.)
    Comment: One commenter supported the approach CMS is taking to 
consolidate the Medicare Part A and Part B claims processing functions 
into one MAC covering several States. The commenter was encouraged that 
this consolidation will promote greater consistency across geographic 
regions. The commenter requested that CMS instruct MACs to review local 
coverage determinations (LCDs) and other policies to ensure consistency 
in coverage between settings of care and to align payment policy and 
incentives between physicians and hospitals.
    Response: As is our current practice, MACs will be required to 
develop LCDs in accordance with Chapter 13 of the CMS Program Integrity 
Manual. As the MACs commence operations in their jurisdictions, each 
MAC will consolidate all of the LCDs for its jurisdiction. CMS will 
continue to issue national coverage determinations (NCDs).
    Comment: Several commenters share the commitment of CMS to 
implement the Medicare contracting reform provisions that are mandated 
by section 911 of the MMA. They requested that CMS grant exceptions to 
the general rule to permit large chain providers to choose an 
appropriate MAC. They believed that allowing providers to choose their 
MAC will ensure maximum efficiency. Another commenter asked if a 
``large chain'' with ``multiple national offices'' could request that a 
specific ``chain office'' be used for consolidation to one MAC 
geographic locale.
    Response: As specified in proposed new Sec.  421.404(b)(3), a 
qualified chain provider approved by CMS to bill a single intermediary 
on behalf of its member providers prior to October 1, 2005, would be 
assigned at an appropriate time to the MAC contracted by CMS to 
administer claims for the applicable Medicare benefit category for the 
geographic locale in which the chain provider's home office is 
physically located. The qualified chain provider would not need to 
request an exception to Sec.  421.404(b)(1). Accordingly, if the 
commenter's reference is to one ``large,'' previously approved, 
qualified chain organization, the qualified chain organization would be 
assigned to the MAC serving the geographic area where the qualified 
chain organization's home office is located. If the commenter's 
reference is to several distinct, previously approved, qualified chain 
organizations that have recently merged, the several distinct legacy 
chains would have to request status as a single qualified chain 
organization in accordance with Sec.  421.404(b)(1); and as part of 
this process, the newly emerged chain organization will be required to 
establish the location of its home office. If CMS approves the request, 
the new qualified chain organization will bill and receive Medicare 
payment from the MAC that covers the geographic locale in which the 
qualified chain organization's home office is located.
    Comment: Several commenters requested that CMS maintain maximum 
flexibility for all parties involved in Medicare contracting reform 
(that is, providers and contractors) during the transitional phases to 
the MACs. They suggested that CMS allow large chain providers the 
ability to maintain their existing relationships with

[[Page 68186]]

intermediaries until all MAC transitions are complete.
    Response: We cannot allow large chain providers to maintain their 
existing relationships with intermediaries until all MAC transitions 
are complete because as intermediary functions are transitioned over 
time to MACs, those intermediaries will no longer be processing claims. 
Those claims will be processed by the ``replacement'' MAC.
    Comment: One commenter requested that CMS provide a mechanism for a 
chain provider that has facilities in many Medicare Part A and Part B 
MAC jurisdictions to consolidate into a smaller number of MACs instead 
of a single MAC in the chain provider's home office jurisdiction.
    Response: The policy announced in proposed Sec.  421.404 allows 
chain providers that meet the requirements for qualified chain 
organization status to request single MAC billing status on behalf of 
its member providers. The process for submitting the request, together 
with the types of documentation the qualified chain organization must 
submit in support of its request, will be set forth in detail in a 
future CMS program manual. A chain provider may make the business 
decision to identify a segment of its organization as a distinct 
qualified chain organization with a regional management office that 
will fall appropriately within one MAC jurisdiction. Our current policy 
does not require that all member providers within the qualified chain 
organization bill through the chain provider's home office MAC. 
However, the future CMS program manual may require that a qualified 
chain organization make clear, in its centralized MAC billing request, 
the identity of each member provider, and which member providers are 
included within the request for centralized billing through the home 
office MAC. The future CMS program manual may require each such 
requesting qualified chain organization, if approved, to maintain that 
centralized billing configuration until a request for another change is 
approved by CMS.
    Comment: Several commenters asked if an existing chain hospital 
that is in a jurisdiction that is transitioning to a MAC, but the 
existing chain provider's home office is not in that jurisdiction, will 
be allowed to continue to bill the intermediary it has been using, or 
must it transition to the contracted MAC in its jurisdiction. The 
commenters also wanted to know whether a chain organization may convert 
to a single MAC to avoid the need for multiple transitions.
    Response: Up until the date a MAC commences operations in the 
jurisdiction where the existing chain provider's home office is 
located, the existing chain provider will be served by the current 
intermediary serving the State in which the existing chain provider's 
home office is located, provided the current intermediary does not end 
its contract prior to the time that the new MAC commences operations. 
Current intermediaries and carriers will complete their contract 
obligations, including serving the existing chain provider's home 
offices. In the event that the servicing intermediary does choose to 
end its contract, CMS will apply Sec.  421.104 in reassigning the 
existing chain provider to another CMS contractor. Our overriding goal 
is to ensure continuity of operations during the period of time current 
contractors are transitioning to MACs.
    Comment: One commenter asked CMS to allow a qualified chain 
organization to select either the MAC that covers the jurisdiction 
where its home office is located, or another MAC that covers the 
jurisdiction where the chain's billing office is located (if 
different), when deciding to consolidate Medicare billing activities.
    Response: For the reasons set forth in the preamble to the proposed 
rule, it is CMS' policy that each qualified chain organization may 
request permission from CMS to bill centrally to one MAC. Further, our 
requirement is that the qualified chain organization must bill the MAC 
responsible for the geographic area where the qualified chain 
provider's home office is located. At this time, we will not allow the 
qualified chain organization to bill based on the location of its 
billing office (if different). Our policy protects the Medicare program 
against chain providers that might seek less restrictive MACs by 
relocating their billing offices. The process for submitting the 
request, together with the types of documentation the qualified chain 
organization must submit in support of its request, will be set forth 
in detail in a future CMS program manual. As we gain experience with 
the MAC environment, we may broaden the centralized billing 
alternatives to support options suggested by the commenter.
    Comment: Several commenters requested that CMS have a clear 
notification and a transition process for notifying providers of 
potential reassignments deemed necessary by the Agency. They requested 
that a full explanation be given for the reasons for determining that 
the change would result in a more efficient and effective 
administration of services.
    Response: We will ensure that providers affected by a transition 
from a legacy Medicare contractor to a MAC are notified in advance of 
the transition. This will be a significant activity within the 
implementation plan for each MAC as the MAC and the provider will need 
to work together on a number of issues (for example, test electronic 
billing arrangements). We have substantial experience in overseeing 
Medicare claims transitions and have refined these processes over many 
years. The reasons for the transition to MACs were set forth in the 
preamble to the rule.
    Comment: Several commenters requested that CMS consider the 
potential impact on providers of delayed claims processing during the 
implementation of the Medicare contracting reform provisions under 
section 911 of the MMA.
    Response: We note that Medicare claims processing timeframes are 
set elsewhere in statute and CMS' program requirements will not be 
affected by the transition to MACs. We will review all MAC contract 
proposals to verify that companies desiring to serve as MACs can meet 
these requirements, and we will closely monitor all transitions to 
ensure that strong program performance is maintained.
    Comment: One commenter commended CMS for requiring MACs to pay 
claims timely. However, the commenter strongly requested that CMS not 
allow a MAC to move to a less frequent payment schedule, believing that 
Medicare claims volumes continue to warrant the most frequent payment 
schedule. The commenter also urged CMS to consider the ability and 
availability of the MAC to meet the needs of the providers assigned to 
the MAC. The commenter believed the MAC should be available during a 
provider's normal business hours, regardless of the provider's location 
within the MAC jurisdiction.
    Response: The commenter raised issues that are outside the scope of 
the proposed rule. In this final rule with comment period, we are not 
responding to those comments. We note that Medicare claims processing 
timeframes are set elsewhere in statute and will not be affected by the 
transition to MACs. We will review the other comments and consider 
whether to take other actions, such as revising or clarifying the MAC 
contracts or CMS' operating instructions or procedures, based on the 
information or recommendations provided in the comments.
    Comment: Several commenters had concerns that newly appointed MACs

[[Page 68187]]

may not have the expertise or familiarity needed to process specialized 
claims such as those for end stage renal disease (ESRD).
    Response: These commenters raised issues that are outside the scope 
of the proposed rule. In this final rule with comment period, we are 
not responding to those comments. We note that we are requiring MACs 
that will administer specialized workloads to demonstrate their 
capability to do so in their contract proposals.
    Comment: Several commenters requested that CMS allow ESRD providers 
the option of having their claims handled by multi-state, regional 
MACs.
    Response: All of the MACs will serve multi-state areas, for example 
one will serve New York and Connecticut. ESRD suppliers will generally 
be assigned to MACs based on Sec.  421.404(c)(1). However, a group of 
ESRD suppliers under common control and common ownership may obtain a 
Sec.  421.404(c)(3) exception if CMS finds the request for centralized 
billing through the home office MAC will support the implementation of 
MACs or will serve some other compelling interest of the Medicare 
program, or both.
    Comment: One commenter cautioned that if a chain were to 
consolidate to just one MAC, there is the potential for an excessive 
workload for a MAC that may have in its jurisdiction many home offices 
for large chain organizations.
    Response: We believe that the MACs will be fully capable of 
administering their chains' workload, but we will monitor the 
concentration of qualified chain organization claims across the 15 
Medicare Part A and Part B MACs.
    Comment: One commenter recommended that CMS permit all of a 
qualified chain organization's member providers within a particular 
area to bill their local, geographically assigned MACs, even if the 
remainder of the qualified chain organization has requested and been 
approved for centralized, home office MAC billing. The commenter 
believed that some local MACs may be better suited to serve a chain's 
providers because LCDs vary across jurisdictions. Specifically, the 
commenter was concerned about a scenario where the home office MAC's 
LCD policy might not cover a hospitalization, even were the local MAC's 
policies might allow a physician to bill under the same clinical 
circumstances. The commenter stated that the typical chain often 
operates a variety of providers and suppliers such as hospitals, 
freestanding imaging centers, and physician offices.
    Response: During the post-award/pre-commencement period, as an 
intermediary or carrier transitions to the selected MAC, the selected 
MAC's medical director will consolidate all the LCDs for the States in 
the MAC's jurisdiction by identifying and implementing the least 
restrictive LCD. This process will alleviate a certain percentage of 
LCD conflict across States. However, a given MAC will apply only the 
LCDs in force in its own jurisdiction. MACs will not be required to 
apply the LCDs of other MACs.
    The choice to request centralized, home office billing is a 
business decision for each qualified chain provider to weigh. We are 
providing this option under Sec.  421.404(b)(2) of the regulations, but 
are not mandating that chains avail themselves of it. We will not 
routinely provide alternatives (other than the general alternative 
provided by Sec.  421.404(b)(1)) because doing so is not generally in 
CMS' administrative interest and could devolve to the former ``provider 
nomination'' environment.
    We note that moving from 20 intermediaries and 18 carriers to 15 
Medicare Part A and Part B MACs has been widely received as a step in 
the right direction by most segments of the Medicare provider community 
and a substantial accomplishment to support the contracting reform goal 
of improving the efficiency and effectiveness of delivering services to 
Medicare beneficiaries and providers.
    Comment: One commenter requested clarification of CMS policy on how 
often qualified chain organization member providers can move in and out 
of centralized billing status. The commenter stated that chains 
frequently change in size and scope of operations, such as the 
establishment of a regional central billing office, and determine that 
it is more efficient to change the billing status for all or some 
member providers. The commenter suggested the status change be 
permitted each fiscal year with a minimum required notice of 120 days 
before the start of the next home office cost reporting period.
    Response: We appreciate the industry's input on workable notice 
requirements. This is a policy detail we will address in the future CMS 
program manual. However, we wish to point out that no provider will be 
allowed to centralize (or decentralize) its billing without CMS 
approval, and we do not anticipate allowing chains to change their 
process frequently. There is a cost to the Medicare Program associated 
with moving providers from one contractor to another, and the lead time 
required will be more than 120 days in many cases.
    Comment: Several commenters recommended that CMS allow companies 
with more than one legal entity, and currently assigned to a single 
intermediary, to continue to bill centrally. They also recommended that 
CMS allow companies with more than one legal entity to apply for single 
MAC status.
    Response: Existing chain providers, including those with more than 
one legal entity, assigned to a single intermediary prior to October 1, 
2005, will be assigned to a single MAC at an appropriate time in 
accordance with Sec.  421.404(b)(3). If a chain provider with more than 
one legal entity, that is assigned to a single MAC, subsequently comes 
to CMS with a request to change the MAC assignment for one of the legal 
entities because of a change in the corporate structure of the overall 
chain, such as spinning off a downstream affiliate, then CMS may 
require the entire chain to reapply for single MAC status, applying the 
then-current CMS qualified chain organization program manual.
    Comment: One commenter recommended that CMS expand the field of 
Sec.  421.404(a) ``eligible providers'' that are entitled to be counted 
among the qualified chain provider's members. The commenter argued that 
allowing otherwise ineligible providers to join in centralized billing 
status would facilitate integration of important functions such as 
coverage rules, provider education, and support for beneficiaries.
    Response: The group of ``eligible providers'' under Sec.  
421.404(a) was established by reference to the provider types that have 
traditionally been eligible to consolidate their billing. At this time, 
we do not intend to extend centralized billing beyond these provider 
types. However, we believe that Sec.  421.404(b)(4) provides CMS the 
discretion to make exceptions if circumstances warrant.
    Comment: Several commenters requested that CMS clarify what is 
meant by the term ``best interest of the program''.
    Response: ``Best interest of the program'' means that which the 
responsible CMS personnel (acting in their official capacity, or 
capacities) determine on a nonarbitrary and noncapricious basis, using 
reasonable judgment and information known to them, to be most 
advantageous to the Medicare program. In making such a determination, 
CMS personnel may balance competing factors and options. The factors 
considered may change over time; for instance, as the Medicare 
program's requirements change,

[[Page 68188]]

technology evolves, and the MACs are implemented.
    Comment: One commenter offered input on the MAC procurement process 
and asked CMS to consider certain performance-related information in 
the awarding of a future MAC contract. Several commenters requested 
that CMS include providers in the contractor selection and renewal 
process. They requested CMS to allow providers to give mid-contract 
reviews of the MACs' performance. One commenter requested that CMS 
ensure that MACs are required to maintain a significant local presence 
inasmuch as each jurisdiction includes several States.
    Response: These commenters raised issues that are outside the scope 
of the provisions of the proposed rule. In this final rule with comment 
period, we are not responding to those comments. However, we will 
review the comments and consider whether to take other actions, such as 
revising or clarifying the MAC contracts or the CMS operating 
instructions or procedures that are issued, based on the information or 
recommendations provided in the comments. We note that the Medicare 
contracting reform statute requires us to measure providers' 
satisfaction with the MACs, and that we will be periodically surveying 
providers for this information.
    Comment: One commenter made an individual-case-specific request. 
One of its ``health care systems'' supposedly was granted centralized 
billing privileges by CMS but the transition to a single intermediary 
was never completed for various reasons. The commenter asked CMS to 
complete the centralized billing transition through the finalization of 
this rule.
    Response: Through a series of ``Medlearn Matters'' articles 
published on the CMS Web site at http://www.cms.hhs.gov/MLNMattersArticles/2005MMA/List.asp#TopOfPage and distributed via 
Listserves and communications with CMS components and affiliated 
contractors in September and October of 2005, CMS notified the Medicare 
community that no requests for provider nomination would be accepted 
beyond October 1, 2005. The public comment and response process 
connected with a notice of proposed rulemaking is not the forum in 
which the Agency treats case-specific requests for qualified chain 
provider or centralized billing status. Chain organizations that have 
experienced a delay in conversion to centralized billing in connection 
with a pre-October 1, 2005 CMS decision to authorize centralized 
billing should contact the CMS component where the original request was 
made and provide documentation of CMS authorization for centralized 
billing. Without the proper documentation, a qualified chain 
organization must wait for CMS to open the period for single-MAC 
billing status. A forthcoming program manual that outlines the process 
for such requests will provide the appropriate instructions.
    After considering the public comments received, we are adopting as 
final, without modification, the proposed provisions of Subpart E of 42 
CFR Part 421 (Sec. Sec.  421.400, 421.401, and 421.404) governing MACs.
3. Other Technical and Conforming Changes
a. Definition of ``Intermediary'' (Sec.  421.3)
    We did not receive any public comments on our proposal to revise 
the definition of the term ``intermediary'' under existing Sec.  421.3 
to delete reference to ``alternative regional intermediaries,'' and, 
therefore, are finalizing it in this final rule with comment period. 
CMS no longer allows HHAs and hospice care providers to select an 
alternative regional intermediary. Over the years, as the number of 
intermediaries in the program has decreased, the availability of 
alternative intermediaries for HHAs and hospices has declined. We have 
implemented the policy that all HHAs and hospice care facilities are to 
be assigned to the designated regional intermediary that serves their 
geographic jurisdiction. This is required for the efficient and 
effective administration of the Medicare program as the agency moves 
forward to implement the MACs.
b. Intermediary Functions (Sec.  421.100)
    Section 1816(a) of the Act, which allowed providers to nominate an 
intermediary, required that only nominated intermediaries perform the 
functions of determining payment amounts and making payments to 
providers. Section 1874A of the Act, as added by section 911 of Public 
Law 108-173, eliminates the intermediary nomination process. All 
activities carried out under intermediary agreements will be 
transitioned to MAC contracts by September 30, 2011.
    During the transition period, CMS will still require regulations to 
support its intermediary agreements. In the proposed rule, we proposed 
to amend Sec.  421.100, concerning functions to be included in 
intermediary agreements, to address the dual intermediary 
responsibilities. We also proposed to revise existing Sec.  421.100(i), 
Dual intermediary responsibilities, to delete the reference to Sec.  
421.117 from this section, as the statutory provision that made this 
necessary was repealed by Public Law 108-173.
    We did not receive any public comments on these proposed technical 
and conforming changes and, therefore, are finalizing them in this 
final rule with comment period without modification.
c. Options Available to Providers and CMS (Sec.  421.103)
    As we proposed, we are finalizing our change of the title of Sec.  
421.103 to ``Payment to Providers'' and revising the contents of Sec.  
421.103 to clarify that all providers must receive payments for covered 
services furnished to Medicare beneficiaries through an intermediary 
(under Sec.  421.404) and eventually through a MAC (under Sec.  
421.404). We are specifying that this function must remain with the 
intermediaries. We will no longer allow providers to receive payments 
directly from CMS, nor will we allow providers to receive payments from 
alternative regional intermediaries. We believe the inclusion of this 
function is consistent with the effective and efficient administration 
of the Medicare program.
    We did not receive any public comments on our proposed technical 
changes.
d. Nomination for Intermediary (Sec.  421.104)
    As we proposed, we are finalizing our change of the title of Sec.  
421.104 to ``Assignment of Providers of Services to Intermediaries 
During Transition to Medicare Administrative Contractors (MACs)'' and 
revising the contents of the section to provide that new providers that 
enter the Medicare program during the transition period will be 
assigned to the local designated intermediary that serves the 
jurisdiction in which the provider is located. We did not receive any 
public comments on the proposed technical change. We believe this 
change is necessary as we prepare to transition from intermediary 
agreements and carrier contracts to contracts with the MACs. In the MAC 
environment, providers will be assigned based on their geographic 
location to the MAC that has jurisdiction for their provider type.
e. Notification of Actions on Nominations, Changes to Another 
Intermediary or to Direct Payment, and Requirements for Approval of an 
Agreement (Sec.  421.105 and Sec.  421.106)
    We did not receive any public comments on our proposal to remove

[[Page 68189]]

Sec.  421.105 and Sec.  421.106 from the regulations; the sections will 
no longer be applicable with implementation of the new Subpart E of 
Part 421. Therefore, we are finalizing the removal in this final rule 
with comment period.
f. Considerations Relating to the Effective and Efficient 
Administration of the Medicare Program (Sec.  421.112)
    We are finalizing our proposal to revise Sec.  421.112 (a). As 
stated previously in this final rule with comment period, provider 
requests to be assigned or reassigned to a particular intermediary will 
no longer be considered. However, we may deem it necessary to reassign 
providers if we find it is necessary for the efficient and effective 
administration of the program. In addition, there will no longer be a 
national intermediary to serve a class of providers.
    We did not receive any specific public comments on this technical 
change.
g. Assignment and Reassignment of Providers by CMS (Sec.  421.114)
    We are finalizing our proposal to revise Sec.  421.114 to specify 
that we may consider it necessary to assign and reassign providers if 
the assignment or reassignment is in the best interest of the program. 
Before making these determinations, we will no longer review provider 
requests to be reassigned to another intermediary. This is consistent 
with the proposed policy to eliminate a provider request to change to 
another intermediary or to direct payment. Under Medicare contracting 
reform, we require increased flexibility to realign providers to 
geographical jurisdictions for effective implementation of the MACs. We 
reserve the right to reassign providers to other jurisdictions if we 
deem it to be in the best interest of the program.
    We did not receive any specific public comments on this proposed 
technical change.
h. Designation of National or Regional Intermediaries (Sec.  421.116) 
and Designation of Regional and Alternative Designated Regional 
Intermediaries for Home Health Agencies and Hospices (Sec.  421.117)
    We are finalizing our proposal to delete Sec.  421.116, Designation 
of national or regional intermediaries, and Sec.  421.117, Designation 
of regional and alternative designated regional intermediaries for HHAs 
and hospices. The statutory provisions that made these regulations 
necessary were repealed by Public Law 108-173. Therefore, we no longer 
need these regulations. All providers will receive payment for covered 
services as described in Sec.  421.103.
    We did not receive any public comments on this proposed technical 
change.
i. Awarding of Experimental Contracts (Sec.  421.118)
    We are finalizing our proposal to delete Sec.  421.118, which 
specifies the provisions under which CMS may award a fixed price or 
performance incentive contract under the experimental authority 
contained in 42 U.S.C. 1395b-1 for performance of intermediary 
functions under Sec.  421.100. The provisions of this section became 
obsolete with the enactment of section 911 of Public Law 108-173.
    We did not receive any public comments on this proposed technical 
change.

XIX. Reporting Quality Data for Improved Quality and Costs Under the 
OPPS

    As noted previously, CMS' Office of the Actuary currently projects 
that Medicare Part B expenditures will continue to grow at a 
significant rate, as a result of rapid growth in the use of both 
physician-related services and hospital outpatient services in the 
original Medicare fee-for-service program. Specifically, the actuaries 
project that the expenditures under the OPPS in CY 2007 will be 
approximately $32.540 billion. This represents approximately a 9.2 
percent increase over our estimated expenditure of $29.809 billion for 
the OPPS in CY 2006, and reflects even more rapid spending growth in 
recent years. As the following table shows, implementation of the OPPS 
has not slowed outpatient spending growth; in fact, double-digit 
spending growth has been occurring.

  Table 52.--Growth in Expenditures Under OPPS from CY 2001 through CY 2007 (Projected Expenditures for CY 2006
                                            and CY 2007) in Billions
----------------------------------------------------------------------------------------------------------------
            OPPS Growth               CY 2001    CY 2002    CY 2003    CY 2004    CY 2005    CY 2006    CY 2007
----------------------------------------------------------------------------------------------------------------
Incurred Cost......................     17.702     19.158    20.8102     23.702     26.518     29.809     32.540
Percent Increase...................  .........        8.2        8.6       13.9       11.9       12.4        9.2
----------------------------------------------------------------------------------------------------------------
Source: FY 2007 Mid-Session Review, Budget of the U.S. Government.

    As we indicated in the CY 2007 OPPS proposed rule, the current rate 
of growth in expenditures for hospital outpatient services is of great 
concern to us. As with the other Medicare fee-for-service payment 
systems that are experiencing rapid spending growth, brisk growth in 
the intensity and utilization of services is the primary reason for the 
current rate of growth in the OPPS, rather than general price or 
enrollment changes. The table below illustrates the increases in the 
volume and intensity of outpatient hospital services over the last 
several years.

                 Table 53.--Percent Increase in Volume/Intensity of Hospital Outpatient Services
----------------------------------------------------------------------------------------------------------------
                                                                                             CY 2005    CY 2006
                                                            CY 2002    CY 2003    CY 2004     (Est.)     (Est.)
----------------------------------------------------------------------------------------------------------------
Percent Increase.........................................        3.5        2.4        7.8        7.8        9.7
----------------------------------------------------------------------------------------------------------------
Source: FY 2007 Mid-Session Review, Budget of the U.S. Government

    For outpatient hospital services, the volume and intensity of 
services for CY 2005 are estimated to continue to increase 
significantly at a rate of 7.8 percent, in excess of the long-term 
trend. This increase follows the 7.8 percent increase in CY 2004, and 
the growth is projected to be 9.7 percent in CY 2006.
    As we have stated repeatedly, this rapid growth in utilization of 
services in

[[Page 68190]]

the OPPS shows that Medicare is paying mainly for more services each 
year, regardless of their quality or impact on beneficiary health. The 
program should promote higher quality services, so that Medicare 
spending is directed in the most efficient manner toward higher quality 
services. Medicare payments should encourage doctors and other 
providers in their efforts to achieve better health outcomes for 
Medicare beneficiaries at a lower cost. Therefore, we have been 
examining the concept of ``value-based purchasing'' in a number of 
payment systems. ``Value-based purchasing'' may use a range of 
incentives to achieve identified quality and efficiency goals, as a 
means of promoting better quality of care and more effective resource 
use in the Medicare payment systems. In developing the concept of 
value-based purchasing, we have been working closely with stakeholder 
partners, including health professionals and providers.
    In the CY 2007 OPPS proposed rule, we sought public comment on 
value-based purchasing as related specifically to hospital outpatient 
departments. As part of our overall goal of promoting value-based 
purchasing in outpatient payment, we also made one specific proposal 
for the CY 2007 OPPS.
    Section 1833(t)(2)(E) of the statute permits the Secretary to 
``establish, in a budget neutral manner, * * * adjustments as 
determined to be necessary to ensure equitable payments'' under the 
OPPS. The absence of OPPS measures to promote high quality in the 
provision of services to Medicare beneficiaries creates an issue of 
payment equity. In general, payments to providers in Medicare's payment 
systems do not vary on the basis of quality or efficiency differences 
among the providers of services. As a result, Medicare's payment 
systems may direct additional resources to hospitals that deliver care 
that is not of the highest quality. For that reason, each Medicare 
dollar spent does not result in the same quality and efficiency of care 
for Medicare beneficiaries.
    We believe that the collection and submission of performance data 
and the public reporting of comparative information about hospital 
performance can provide a strong incentive to encourage hospital 
accountability in general and quality improvement in particular. 
Measurement and reporting can focus the attention of hospitals and 
consumers on specific goals and on hospitals' performance relative to 
those goals. Development and implementation of performance measurement 
and reporting by hospitals can thus produce quality improvement in 
actual health care delivery. Hospital performance measures may also 
provide a foundation for performance-based rather than volume-based 
payments, which are used in the OPPS today.
    We have obtained some evidence of the potential for improving 
quality of care in hospitals by means of the collection and submission 
of performance data from the Premier Hospital Quality Incentive 
Demonstration.\1\ This demonstration was designed to test whether the 
quality of inpatient care for Medicare beneficiaries can improve when 
financial incentives are provided. Under the demonstration, about 270 
hospitals of Premier, Inc., a nationwide alliance of not-for-profit 
hospitals, have been voluntarily providing data on 34 quality measures 
related to five clinical conditions: heart attack, heart failure, 
pneumonia, coronary artery bypass graft, and hip and knee replacements. 
Using the quality measures, CMS identifies hospitals with the highest 
quality performance in each of the five clinical areas. Hospitals 
scoring in the top 10 percent in each clinical area receive a two 
percent bonus payment in addition to the regular Medicare DRG payment 
for the measured condition. Hospitals in the second highest 10 percent 
receive a one percent bonus payment. In the third year of the 
demonstration, if hospitals do not achieve absolute improvements above 
the demonstration's first year composite score baseline (the lowest 20 
percent) for that condition, they will have their DRG payments reduced 
by one or two percent, depending on how far their performance is below 
the baseline.
---------------------------------------------------------------------------

    \1\ The Premier Hospital Quality Incentive Demonstration was 
authorized under section 402 of Pub. L. 90-248, Social Security 
Amendments of 1967 (42 U.S.C. 1395b-1). This section authorizes 
certain types of demonstration projects that waive compliance with 
the regular payment methods used in the Medicare program.
---------------------------------------------------------------------------

    Following the first year of the demonstration (FY 2004), CMS 
awarded a total of $8.85 million to participating hospitals in the top 
two deciles for each clinical area. In the aggregate, quality of care 
improved in all five clinical areas that were measured. Preliminary 
information from the second year of the demonstration indicates that 
quality is continuing to improve, particularly for the hospitals that 
were initially poorest performing.\2\ We believe that these results 
indicate that reporting of quality data may in and of itself lead to 
improved outcomes for Medicare beneficiaries.
---------------------------------------------------------------------------

    \2\ Additional information on the Premier Hospital Quality 
Incentive Demonstration is available on the CMS Web site at: http://www.cms.hhs.gov/HospitalQualityInits/35_HospitalPremier.asp.
---------------------------------------------------------------------------

    Since 2003, we have operated the Hospital Quality Initiative,\3\ 
which is designed to stimulate improvements in inpatient hospital care 
by standardizing hospital performance measures and data transmission to 
ensure that all payers, hospitals, and oversight and accrediting 
entities use the same measures when publicly reporting on hospital 
performance. Section 501(b) of Public Law 108-173 authorized us to link 
the collection of data for an initial starter set of 10 quality 
measures to the hospital IPPS annual payment update. In order to 
implement this provision, we created the Reporting Hospital Quality 
Data for Annual Payment Update (RHQDAPU) program. For FYs 2005 and 
2006, hospitals that met the RHQDAPU program's requirements received 
the full IPPS annual payment update, while hospitals that did not 
comply received an update that was reduced by 0.4 percentage points. 
For FY 2005, virtually every hospital in the country that was eligible 
to participate submitted data (98.3 percent), and approximately 96 
percent of all participating hospitals met the requirements to receive 
the full update. The data regarding the starter set of 10 quality 
measures, as well as additional, voluntarily reported data on other 
quality measures, are available to the public through the Hospital 
Compare Web site at: http://www.hospitalcompare.hhs.gov.
---------------------------------------------------------------------------

    \3\ Additional information on CMS' Hospital Quality Initiative 
is available on the CMS Web site at: http://www.cms.hhs.gov/HospitalQualityInits/.
---------------------------------------------------------------------------

    The starter set of 10 quality measures that was established for the 
IPPS RHQDAPU as of November 1, 2003, are:

Heart Attack (Acute Myocardial Infarction/AMI)

     Was aspirin given to the patient upon arrival to the 
hospital?
     Was aspirin prescribed when the patient was discharged?
     Was a beta-blocker given to the patient upon arrival to 
the hospital?
     Was a beta-blocker prescribed when the patient was 
discharged?
     Was an ACE inhibitor given for the patient with heart 
failure?

Heart Failure (HF)

     Did the patient get an assessment of his or her heart 
function?
     Was an ACE inhibitor given to the patient?

Pneumonia (PNE)

     Was an antibiotic given to the patient in a timely way?

[[Page 68191]]

     Had the patient received a pneumococcal vaccination?
     Was the patient's oxygen level assessed?
    For FY 2007 and each subsequent year, section 5001(a) of Public Law 
109-171 amended section 1886(b)(3)(B) of the Act and made changes to 
the program established under section 501(b) of Public Law 108-173. 
These changes require us to expand the number of measures for which 
data must be submitted, and to change the percentage point reduction in 
the annual payment update from 0.4 percentage points to 2.0 percentage 
points for IPPS hospitals that do not report the required quality 
measures in a form and manner, and at a time, specified by the 
Secretary.
    Effective for payments beginning with FY 2007, new section 
1886(b)(3)(B)(viii)(IV) of the Act requires the Secretary to begin to 
adopt the expanded set of performance measures set forth in the IOM's 
2005 report entitled, ``Performance Measurement: Accelerating 
Improvement.'' \4\ Those measures include the HQA measures and the 
HCAHPS patient perspective survey. Effective for payments beginning 
with FY 2008, the Secretary must add other measures that reflect 
consensus among affected parties and may replace existing measures as 
appropriate. New section 1886(b)(3)(B)(viii)(VII) of the Act requires 
the Secretary to post hospital quality data on these measures on the 
CMS Web site. The expanded set of 21 quality measures for the FY 2007 
update that was included in the FY 2007 IPPS final rule (71 FR 48033) 
is outlined below:
---------------------------------------------------------------------------

    \4\ Institute of Medicine, ``Performance Measurement: 
Accelerating Improvement,'' December 1, 2005, available at http://www.iom.edu/CMS/3809/19805/31310.aspx.
---------------------------------------------------------------------------

Heart Failure (Acute Myocardial Infarction/AMI)

     Aspirin at arrival
     Aspirin prescribed at discharge
     ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker 
(ARBs) for left ventricular systolic dysfunction
     Beta blocker at arrival
     Beta blocker prescribed at discharge
     Thrombolytic agent received within 30 minutes of hospital 
arrival
     Percutaneous Coronary Intervention (PCI) received within 
120 minutes of hospital arrival
     Adult smoking cessation advice/counseling

Heart Failure (HF)

     Left ventricular function assessment
     ACE inhibitor (ACE-1) or Angiotensin Receptor Blocker 
(ARBs) for left ventricular systolic dysfunction
     Discharge instructions
     Adult smoking cessation advice/counseling

Pneumonia (PNE)

     Initial antibiotic received within 4 hours of hospital 
arrival
     Oxygenation assessment
     Pneumococcal vaccination status
     Blood culture performed before first antibiotic received 
in hospital
     Adult smoking cessation advice/counseling
     Appropriate initial antibiotic selection
     Influenza vaccination status

Surgical Care Improvement Project (SCIP)

     Prophylactic antibiotic received within 1 hour prior to 
surgical incision
     Prophylactic antibiotics discontinued within 24 hours 
after surgery end time
    In order to receive the full FY 2007 IPPS update, hospitals are 
required to continue to collect data for all 10 starter set quality 
measures (or begin collecting such data, if newly participating in the 
program) and are required to provide a written pledge to submit data on 
the set of 21 expanded quality measures, in addition to completing 
several administrative tasks regarding quality reporting. All of the 
measures for the IPPS RHQDAPU program are to be reported on inpatient 
hospital discharges.
    In the CY 2007 OPPS proposed rule, we proposed to employ our 
equitable adjustment authority under section 1833(t)(2)(E) of the Act 
to adapt the quality improvement mechanism provided by the IPPS RHQDAPU 
program for use in the OPPS. As we have discussed above, failure to 
account at all for quality in payment systems raises a fundamental 
issue of payment equity. In the absence of mechanisms that provide 
incentives for higher quality care, Medicare's payment systems can 
direct more resources to hospitals that do not deliver high quality 
care to Medicare beneficiaries.
    In the proposed rule, we proposed to initiate a Reporting Hospital 
Quality Data for Annual Payment Update under the OPPS (OPPS RHQDAPU 
program), effective for payments beginning January 1, 2007. We proposed 
to add a new Sec.  419.43(h) to our regulations to implement this 
proposal. Under proposed new Sec.  419.43(h)(1), we would initially 
implement an OPPS RHQDAPU program by reducing the OPPS conversion 
factor update in CY 2007 for those hospitals that are required to 
report quality data under the IPPS RHQDAPU program in order to receive 
the FY 2007 update, and fail to meet the requirements for receiving the 
full FY 2007 IPPS payment update. These hospitals would receive an 
update to the CY 2007 OPPS conversion factor that is reduced by 2.0 
percentage points. Under proposed Sec.  419.43(h)(2), any reduction 
would not affect a hospital's OPPS update in a subsequent calendar 
year. Hospitals that meet the IPPS RHQDAPU program's requirements for 
FY 2007 and receive the full IPPS annual payment update would also 
receive the full update to the conversion factor used to determine 
payments for CY 2007 under the OPPS.
    In the proposed rule, we indicated that, for this initial phase of 
implementing an OPPS RHQDAPU program in CY 2007, it would be necessary 
to provide an exception for certain hospital outpatient departments to 
the requirement that quality data be submitted under the IPPS RHQDAPU 
program in order to receive the full OPPS update. The quality data 
submission requirements of the IPPS RHQDAPU program apply only to 
``subsection (d)'' hospitals. ``Subsection (d)'' hospitals are defined 
under section 1886(d)(1)(B) of the Act as hospitals that are located in 
the 50 States or the District of Columbia other than those categories 
of hospitals or hospital units that are specifically excluded from the 
IPPS, including psychiatric, rehabilitation, long-term care, 
children's, and cancer hospitals or hospital units. In other words, the 
provision does not apply to hospitals and hospital units excluded from 
the IPPS, or to hospitals located in Puerto Rico or the U.S. 
territories. For the initial stage of implementing the OPPS RHQDAPU 
program in CY 2007, hospitals that are paid under the OPPS but that do 
not qualify as ``subsection (d)'' hospitals would continue to receive 
the full update to the OPPS conversion factor. However, as we explained 
in the proposed rule, our intention was to expand the OPPS RHQDAPU in 
the future program by requiring all hospitals that receive payment 
under the OPPS to participate in the program in order to receive a full 
update, by appropriate expansion, adaptation, and/or extension of 
quality performance measures and quality reporting mechanisms.
    In the proposed rule, we explained that we believe that it is fair 
and appropriate, for purposes of the initial phase of implementing an 
OPPS RHQDAPU program, to take timely and accurate reporting of IPPS 
RHQDAPU program quality measures into account

[[Page 68192]]

under our equitable adjustment authority. We believe that the 10 
original quality measures and the expanded set of 21 process measures 
as reported for inpatient discharges for heart attack, heart failure, 
pneumonia, and surgical care reflect the quality of care in the 
outpatient department as well as the inpatient hospital, so they are 
appropriate for initial use in the OPPS as specific measures are being 
developed to reflect the quality of care for hospital outpatients. We 
believe that hospitals generally function as integrated systems that 
provide health care services to patients in both inpatient and 
outpatient settings for many of the same clinical conditions, while 
recognizing the different typical levels of acuity in the two settings. 
Hospital quality measures for multiple conditions reflect, in part, the 
systems of care established by hospitals in the outpatient setting such 
as the emergency department. Therefore, the well-developed quality 
measures reported for the FY 2007 IPPS regarding inpatient hospital 
discharges should reasonably represent the quality of care provided to 
hospital outpatients, so we proposed their interim use for the CY 2007 
OPPS while quality measures specific to hospital outpatients are being 
developed and refined. This use of multiple measures for several 
clinical conditions serves as a proxy for the quality of the systems of 
care established by hospitals. As we expand quality measurement for the 
hospital outpatient setting, we intend to move from measures that serve 
as proxies for the quality of care to actual performance measures for 
the outpatient setting. The discussion below focuses on the expanded 
list of 21 quality of care measures, as the 10 original measures 
continue to be included in the quality measurement expansion.
    There are seven quality measures assessing the processes of care 
for patients presenting to the hospital with an acute myocardial 
infarction, focused on the care on arrival, the promptness of 
interventions, and discharge care. As we noted in the proposed rule, 
for the common urgent condition of a patient presenting to the hospital 
with chest pain that results in a clinical suspicion of acute 
myocardial infarction, in their effort to provide consistent, high 
quality care that is founded on evidence-based guidelines, hospitals 
often utilize clinical care pathways that are standardized for such 
patients presenting to the emergency room of the hospital. Such care 
pathways generally apply to patients with specific medical conditions 
who present to the hospital initially as outpatients, regardless of 
their eventual discharge home from the outpatient department or 
inpatient admission. Thus, we believe that all seven of these measures 
likely serve as reasonable proxies for the quality of care for patients 
presenting to the hospital outpatient department with chest pain 
related to a myocardial infarction, who commonly receive care along the 
continuum from outpatient to inpatient services in a hospital that 
provides such care in an integrated system.
    Similarly, there are seven process measures related to the care of 
patients with pneumonia, who often present urgently to the hospital's 
emergency room with symptoms suggestive of the diagnosis of pneumonia. 
Because of the established clinical evidence regarding assessment and 
treatment activities that improve the quality of care for patients with 
pneumonia, most of the interventions that are measured, including 
oxygenation assessment, drawing of blood cultures, assessment of the 
patient's pneumococcal and influenza vaccine status, and selection and 
provision of an initial antibiotic in a timely manner, would generally 
be performed in the outpatient department, sometimes prior to a 
clinical decision about the patient's ultimate need for inpatient 
admission. In particular, the measures of vaccine status are quality 
measures that may be especially appropriate as hospital outpatient 
prevention measures. Their use in the hospital setting provides an 
opportunity for quality improvement in the hospital by encouraging 
assessment of immunization status and appropriate provision of 
immunizations, so we see no reason why their reporting on hospital 
inpatients is not also reflective of the quality of hospital outpatient 
care. While we acknowledge that, in general, the clinical picture of 
patients who are admitted to the hospital with pneumonia differs from 
that of patients who are not hospitalized, we expect there to be many 
common elements in their assessment, treatment, and counseling 
regarding the significance of smoking as the hospital provides their 
initial and subsequent care in the outpatient and/or inpatient 
settings. Therefore, we believe that all seven of the measures related 
to the treatment of pneumonia are likely appropriately reflective of 
the quality of the care systems established by hospitals for 
outpatients with a diagnosis of pneumonia.
    There are four quality measures related to the treatment of 
patients with heart failure, including assessment of their cardiac 
function, use of certain medications in their treatment, counseling 
regarding smoking cessation, and provision of discharge instructions. 
Patients with heart failure, a common chronic medical condition, are 
seen frequently in hospital clinics and emergency departments with 
exacerbations of their symptoms. Once again, their initial treatment is 
often standardized and provided in the outpatient setting without 
consideration of their eventual discharge from the outpatient 
department or inpatient admission, a decision that ultimately depends 
on clinical considerations, including their response to treatment. 
Thus, we believe that all four of the inpatient quality measures 
regarding the treatment of patients with heart failure are reasonable 
surrogates for the quality of hospital systems of care for outpatients 
with heart failure.
    Likewise, under the expanded list of quality measures for the FY 
2007 IPPS the surgical infection prevention quality measures indicating 
the provision of a prophylactic antibiotic within 1 hour prior to 
surgical incision and prophylactic antibiotics discontinued within 24 
hours after surgery end time likely serve as a reasonable 
representation of the quality of surgical care for hospital 
outpatients. Many of the same surgical procedures are commonly 
performed on both hospital outpatients and inpatients, sometimes in the 
same operating room suites with attendance by the same clinical staff. 
Hospitals often have standardized protocols for providing antibiotics 
prior to surgery and postoperatively based on the types of procedures 
performed, rather than on the inpatient or outpatient status of the 
patient, and a decision to admit a patient may not even be made until 
after the completion of a procedure. Thus, we have no reason to believe 
that the preoperative and postoperative antibiotic experiences of a 
patient undergoing outpatient surgery would systemically vary from that 
of a hospital inpatient.
    In summary, in the CY 2007 OPPS proposed rule we concluded that we 
believe that quality improvement is usually a function of the entire 
institution as an integrated system that provides both inpatient and 
outpatient services to patients with an overlapping range of medical 
conditions. Quality improvement in a hospital inpatient department is 
likely to correlate with, and indeed to promote, similar quality 
improvement in the hospital's outpatient department and other sectors 
of the institution. Conversely, hospitals that fail to promote quality 
improvement in key sectors such as inpatient care are also unlikely to 
improve quality in the hospital

[[Page 68193]]

outpatient department. We believe that the FY 2007 IPPS quality 
measures for multiple clinical conditions reflect the quality of 
hospitals' systems of care that customarily include key outpatient 
settings such as the emergency department. Therefore, as an interim 
step while specific quality measures are being developed and refined 
for reporting on the quality of care to hospital outpatients, we 
proposed that the initial CY 2007 OPPS RHQDAPU incorporate all of the 
quality measures that are applicable to the IPPS during FY 2007.
    In the proposed rule, we welcomed public comments on the 
applicability to the OPPS of the various FY 2007 IPPS quality measures 
as proxies for the quality of care in hospital systems that include 
outpatient departments, with consideration of both the 10 starter set 
measures and the 11 new measures in the expanded set for FY 2007.
    In the proposed rule, we also discussed our proposed additional 
quality measures for hospital reporting of quality data for the FY 2008 
IPPS. The proposed areas of expansion for the FY 2008 IPPS include the 
HCAHPS survey, which incorporates questions measuring patients' 
perspectives of their hospital experiences; 3 additional measures 
related to the processes of surgical care to supplement the 2 initial 
Surgical Care Improvement Project (SCIP) measures to be implemented in 
FY 2007; and 3 risk-adjusted assessments of mortality within 30 days of 
hospital admission for acute myocardial infarction, heart failure, and 
pneumonia. For the same reasons detailed above for the FY 2007 IPPS 
SCIP measures, in the proposed rule we explained that we believe that 
the additional surgical process of care measures are a reasonable 
interim proxy for the quality of surgical care for hospital 
outpatients.
    In addition, the questions on the hospital HCAHPS survey assess 
aspects of the patient's hospital experience, including communication 
with doctors and nurses, responsiveness of the staff, pain management, 
and discharge information. These areas of questioning are all relevant 
to a hospital's care for its outpatients, who may be treated in the 
hospital outpatient department for an extended period of time, 
particularly if they are in observation status or recovering from a 
significant surgical procedure. As described above, because hospitals 
generally function as integrated systems, with both inpatients and 
outpatients with related medical conditions passing through the same 
departments and interacting with similar staff, we believe that this 
survey of patients who have been admitted to the hospital may 
reasonably reflect hospital outpatients' perspectives on their care 
experiences as well.
    Finally, with respect to the 30-day mortality measures, these 
measures are linked to the same three medical conditions for which 
quality process measures have already been implemented in the IPPS 
RHQDAPU program, in order to expand the quality data to more fully 
reflect the true outcomes of care. These mortality measures are risk-
adjusted based on historical medical care use, including inpatient and 
outpatient hospital care and physician office visits, and reflect 
outcomes of care specifically for Medicare patients. Because we 
proposed that the full set of FY 2007 IPPS process of care quality 
measures are acceptable proxies for the quality of care to hospital 
outpatients as previously discussed, and we believe that some of the 
value of health care process measures is their relative ease of 
measurement and their ultimate relationship to health outcomes, we 
believe that the 30-day mortality measures for inpatients may also 
reflect the quality of care to hospital outpatients with the same 
medical conditions. In addition, in view of the common clinical courses 
of acute myocardial infarction, heart failure, and pneumonia in 
Medicare beneficiaries, it is highly likely that hospital outpatient 
services may be provided to previously hospitalized patients within the 
measures' timeframe of 30 days after hospital discharge, thereby 
contributing to their care and health outcomes.
    Therefore, in the CY 2007 OPPS proposed rule we stated our 
intention to adopt the full set of FY 2008 IPPS quality measures as 
proposed for the CY 2008 OPPS RHQDAPU program, while we continue to 
develop a set of specific quality measures for hospital outpatient 
care.
    In the CY 2007 OPPS proposed rule, we welcomed public comments on 
the applicability of the FY 2008 IPPS additional quality measures that 
we proposed to the care of hospital outpatients. We also welcomed 
public comments on alternative measures of quality of care, including 
measures of the cost or efficiency of care, that are suitable for 
adoption to reduce the incidence of lower-quality and high-cost 
outpatient hospital care for Medicare beneficiaries. We indicated that 
we would formalize our proposal regarding the CY 2008 OPPS RHQDAPU 
program in the CY 2008 OPPS proposed rule, which may include proposing 
to adopt none, some, or all of the FY 2008 IPPS RHQDAPU measures, and 
may also reflect quality measures that are discussed in comments on 
this proposed rule.
    For purposes of computing the update to the conversion factor under 
the OPPS in CY 2007, we proposed to reduce the update to the OPPS 
conversion factor by 2.0 percentage points for any hospital that is 
eligible to participate in the IPPS RHQDAPU program, but that has had 
its IPPS payment update reduced because it failed to comply with that 
program's requirements. Under this proposal, hospitals that fail to 
qualify for the full CY 2007 OPPS update would receive payments based 
on a proposed conversion factor of $60.36, reflecting an update of 1.4 
percent, in place of the proposed conversion factor of $61.551 
reflecting the full update of 3.4 percent.
    We proposed to add a new Sec.  419.43(h) to incorporate our 
proposal. Under proposed Sec.  419.43(h)(1), in order to avoid 
reduction to the CY 2007 OPPS update, hospitals that are eligible to 
participate in the IPPS RHQDAPU program must meet the requirements for 
receiving the full IPPS update for FY 2007. Updated procedures and 
requirements for the IPPS RHQDAPU program are included in the FY 2007 
IPPS final rule. In addition to publication in the final rule, all 
revised procedures will be added to the ``Reporting Hospital Quality 
Data for Annual Payment Update Reference Checklist'' section of the 
QualityNet Exchange Web site (http://www.qnetexchange.org). For 
purposes of determining which hospitals have not qualified to receive 
the full update under the OPPS for CY 2007, we indicated in the 
proposed rule that we would follow the determination for FY 2007 full 
IPPS payment update eligibility under the IPPS RHQDAPU program. Since 
publication of the CY 2007 OPPS proposed rule, CMS has determined that 
171 hospitals are not eligible to receive the full FY 2007 IPPS payment 
update. As we noted above, we proposed this initiative under the 
authority granted by section 1833(t)(2)(E) of the Act, which authorizes 
the Secretary to ``establish, in a budget neutral manner, * * * 
adjustments as determined to be necessary to ensure equitable 
payments'' under the OPPS. Proposed Sec.  419.43(h)(3) provided that 
the reduction to the CY 2007 update that we will implement for 
hospitals that fail to meet the requirements described above will be 
implemented in a budget neutral manner. Therefore, if we determine that 
some hospitals would receive a reduced update for CY 2007 as a result 
of failure to meet the requirements established under this initial 
phase of the OPPS RHQDAPU program, we would also

[[Page 68194]]

make an adjustment to the OPPS conversion factor, so that estimated 
aggregate payments under the OPPS for CY 2007, taking into account the 
reduced update for some hospitals, equal the aggregate payments that we 
estimate would have been made in CY 2007 if all hospitals received the 
full update to the conversion factor. As we noted above, determinations 
concerning which hospitals failed to meet the requirements for 
receiving the full update to the OPPS conversion factor in CY 2007 were 
available in September 2006. During the development of the proposed 
rule, we were unable to determine how many hospitals would receive a 
reduced update in CY 2007, or to determine the budget neutrality 
adjustment factor that would be necessary to ensure that estimated 
aggregate payments under the OPPS for CY 2007 did not change as a 
result of implementing the proposed OPPS RHQDAPU program. However, we 
noted that very few hospitals had previously failed to qualify for the 
full annual updates under the IPPS RHQDAPU program. Therefore, we 
anticipated that any further adjustment to the CY 2007 conversion 
factor to satisfy the budget neutrality requirement under section 
1833(t)(2)(E) of the Act would be negligible. Our projections were 
correct, as only a few hospitals were not eligible to receive the full 
FY 2007 IPPS update.
    We explained in the proposed rule that it was not our intention to 
maintain the specific requirements described above beyond a short 
initial phase of implementing an OPPS RHQDAPU program. Rather, our 
intention is to develop this program beyond its initial stage in at 
least two ways. As we have stated previously, we believe that it is 
appropriate and fair during this initial phase of the OPPS RHQDAPU 
program to take quality data reporting under the IPPS RHQDAPU program 
into consideration for purposes of determining the update for hospitals 
under the OPPS. However, it would be important for a fully developed 
OPPS RHQDAPU program to be based on reporting measures that are defined 
in terms of the quality considerations that are most appropriate and 
applicable in the hospital outpatient setting. In collaboration with 
health care stakeholders, we indicated in the proposed rule that we 
intend to begin work on a set of quality and cost of care measures 
specific to hospital outpatient departments for implementation in a 
later phase of the OPPS RHQDAPU program. We said that we intend to 
implement a hospital outpatient-specific set of such quality and cost 
of care measures at the earliest possible date. Reporting of a more 
fully developed, outpatient-specific set of quality and cost of care 
measures may be effective for purposes of determining the update as 
early as CY 2009. However, in implementing the system, we explained 
that we would allow adequate time for development of the appropriate 
measures; announcement of the quality and cost of care measures we have 
selected; consideration of comments from the hospital community, 
patient advocates, and other stakeholders; establishment of the 
requisite mechanisms for reporting the measure; and initiation of 
actual reporting of the measures by hospitals. As we begin to develop 
such a set of hospital outpatient-specific quality and cost of care 
measures, in the proposed rule we welcomed comments on this issue.
    Specifically, in the CY 2007 OPPS proposed rule, we invited 
comments on the following (and related) questions: Which current 
quality and cost of care measures, such as IPPS quality measures 
(especially the measure set as expanded under the DRA), physician 
practice measures, HCAHPS/ACAHPS[supreg] etc., are most applicable in 
the hospital outpatient setting? What would be the characteristics of 
an ideal measure set of quality and cost of care measures for the 
outpatient setting? What quality and cost of care measures are 
currently available for the outpatient setting? What privately-led 
organizations or alliances are best suited to conduct needed 
development and consensus endorsement of outpatient quality measures?
    As we discussed above and we proposed for the initial stage of 
implementing the OPPS RHQDAPU program in CY 2007, hospitals that are 
paid under the OPPS but that do not qualify as ``subsection (d)'' 
hospitals would receive the full update to the OPPS conversion factor. 
However, we believe that it is essential to expand the requirements of 
the OPPS RHQDAPU program that we proposed to all hospital outpatient 
departments paid under the OPPS. Therefore, we indicated that we would 
also undertake to study, for CYs 2008 and beyond, approaches to 
adapting and expanding the current quality and cost of care measures 
under the IPPS RHQDAPU program for use in reporting on the quality of 
outpatient care in hospitals that are paid under the OPPS but that do 
not qualify as ``subsection (d)'' hospitals. We explained that we would 
also begin development of mechanisms by which these hospitals could 
report the requisite quality data in a timely and effective manner. In 
the proposed rule, we welcomed comments on ways in which we could 
expand the proposed OPPS RHQDAPU program to all hospital outpatient 
departments that are paid under the OPPS, and on quality and cost of 
care measures that are specifically appropriate for reporting by 
hospital outpatient departments paid under the OPPS but that do not 
qualify as ``subsection (d)'' hospitals.
    In the proposed rule, we explained that our ultimate goal is 
implementation of an OPPS RHQDAPU program that extends to all hospital 
outpatient departments that are paid under the OPPS, that is based on a 
set of quality and cost of care reporting measures that are specific to 
the hospital outpatient setting, and that is appropriately aligned with 
developments in quality reporting and value-based purchasing in other 
payment systems such as the IPPS. We noted that we would take into 
consideration issues related to the appropriate alignment of quality 
and cost of care reporting and value-based purchasing under the IPPS 
and OPPS during the planning process mandated by section 5001(b) of the 
DRA for implementation of inpatient value-based purchasing by FY 2009. 
We explained that we plan to include all hospital services, whether 
inpatient or outpatient, in the report on implementation of value-based 
purchasing. We have often heard from stakeholders that a more 
comprehensive, systematic approach to quality should be our focus. 
Quality reporting of inpatient and outpatient services is consistent 
with such comments, and would provide more comprehensive information 
about the quality of services provided by hospitals. In the proposed 
rule, we requested comments on the alignment of scope and other issues 
that should be considered during this planning process, including 
quality and cost of care reporting measures, data and program 
infrastructure, incentives, and public reporting of quality and cost of 
care measures under value-based purchasing.
    Finally, in the CY 2007 OPPS proposed rule, we requested comments 
on the most effective use of our authority under section 1833(t)(2)(E) 
of the Act, in light of the concerning evidence of rapid and uneven 
payment growth in the OPPS with limited evidence of patient benefit. In 
particular, we indicated that commenters who believe that the proposed 
quality reporting initiative is not the most effective use of this 
authority should consider submitting comments on alternative, more 
effective approaches to using this and related

[[Page 68195]]

authorities available to CMS under the Act to promote higher quality, 
more equitable care. We stressed that we did not believe that the 
status quo, with rapid and uneven growth in spending and limited 
evidence of its value, was consistent with an efficient hospital 
outpatient payment program and value-driven health care for Medicare 
beneficiaries, and we expect to take further steps to address this 
important concern. In addition, we sought comment on whether section 
1833(t)(2)(F) of the Act also supports the proposed use of quality 
reporting to determine a hospital's update under the OPPS.
    Comment: Some commenters generally supported the proposal to reduce 
the update to the OPPS conversion factor for CY 2007 for those 
hospitals that are required to report quality data under the IPPS 
RHQDAPU program in order to receive the FY 2007 update and fail to meet 
the requirements for receiving the full FY 2007 IPPS payment update. 
One commenter characterized the proposal as ``an important and laudable 
project.'' However, this commenter also expressed concern that the 
projected expansion of reporting to additional, outpatient-specific 
measures would require significant increases in hospital resources, 
including additional staff and increased vendor workload. Another 
commenter agreed with the agency's goals of adopting value-based 
purchasing and promoting higher quality services. This commenter 
expressed concern, however, that the adoption of the IPPS standards 
might delay development of standards that are appropriate to outpatient 
care. Another commenter supported the proposal as an interim step 
toward development and reporting of quality measures that are most 
appropriate to the hospital outpatient department setting. This 
commenter noted that the proposed reduction to a hospital's outpatient 
payment update would provide an additional incentive to spur the 
submission of the inpatient quality data. Commenters also recommended 
that CMS evaluate the effectiveness of reporting quality data and 
consider increasing the reduction or shifting the application of the 
reduction to reflect actual performance rather than mere reporting.
    Another commenter supported the effort to improve the quality of 
care in hospital outpatient departments. This commenter offered 
specific suggestions for revising the proposed list of quality measures 
for use in the hospital outpatient department setting. For example, the 
commenter recommender that the heart attack (Acute Myocardial 
Infarction/AMI) measures be expanded to reflect current standards of 
care, which include provision of both aspirin and clopidogrel bisulfate 
to patients with Acute Coronary Syndrome on discharge.
    One commenter said that it was not clear whether CMS was proposing: 
(1) That hospitals must report the IPPS measures for outpatient 
services to prevent a 2.0 percent reduction on their FY 2007 conversion 
factor update, or (2) that hospitals that report all of the IPPS 
measures will automatically receive the full OPPS update. The commenter 
strongly objected to the application of the IPPS measures to outpatient 
hospital services and said that CMS should consolidate the various 
silos of measures into a single set of quality measures that promote 
patient-centeredness, episodes of care, the continuum of care, and 
disease management. The commenter also stated that there needs to be a 
national measurement framework for establishing the priorities for 
outpatient measures and that when outpatient measures are constructed, 
there should be testing prior to public reporting of the findings. 
However, the commenter also expressed support for a policy that CMS 
``use the evidence of IPPS reporting to influence the OPPS conversion 
factor update for CY 2007 * * *.'' This commenter supported this 
``extra incentive for hospital quality reporting,'' on the grounds that 
it ``is imperative that all hospitals participate in this avenue for 
accountability and quality improvement. Thus, basing a portion of OPPS 
payment on whether hospitals report their IPPS measures is warranted.''
    One commenter noted that some hospitals are still attempting to 
master the original inpatient measures. The commenter suggested the 
most appropriate time to add outpatient quality indicators would be 
that when this task has been mastered. The commenter also suggested the 
non-inpatient indicators should be added for all entities at the same 
time, noting that the CMS proposal under the OPPS does not apply to 
ambulatory surgical centers.
    Finally, one commenter agreed that there is some correlation 
between outpatient and inpatient care for the specific diagnoses 
included in the current IPPS reporting measures, but expressed some 
concern about the use of the IPPS measures as a proxy for the quality 
of hospital outpatient services. The commenter suggested that 
modification of some current inpatient measures to include outpatients 
could provide an interim methodology. However, the commenter also 
stated that there should not be a rush to put outpatient measures into 
place without prior review of such modifications by all stakeholders.
    A number of other commenters strongly opposed our proposal. Several 
commenters objected that the proposal was unfair because it would take 
into account reporting that hospitals had already performed before they 
became aware of the additional payment reduction proposed under the 
OPPS for failure to report the measures. Some of these commenters 
expressed the view that, in this respect, the proposal amounted to 
retroactive rulemaking, since hospitals could now take no action to 
avoid a potential reduction to their CY 2007 payments if the proposal 
is adopted. Other commenters objected that the proposal exceeds CMS' 
statutory authority.
    Some of these commenters argued that the congressional mandate of 
quality reporting in the hospital inpatient and home health settings 
precludes CMS from extending reporting into the hospital outpatient 
setting without such specific statutory authority. These and other 
commenters also objected that section 1833(t)(2)(E) of the Act, which 
allows the Secretary to establish ``other adjustments as determined to 
be necessary to ensure equitable payments,'' does not provide adequate 
statutory authority to tie hospital outpatient payments to quality 
reporting. In addition, some commenters noted that unlike other 
adjustments proposed for the CY 2007 OPPS, there appeared to be no 
provision for the amounts not spent in the full update for hospitals 
that did not meet the IPPS quality reporting standards to be returned 
to other providers through increases in payment. They believe that this 
proposal appeared to be a penalty, rather than an equitable adjustment.
    Some commenters also objected to the proposed linkage of outpatient 
payment to inpatient measures of quality. Several commenters stated 
that the IPPS quality measures have no documented validity for 
outpatient care and services. Other commenters stated that the 
inpatient measures are not appropriate proxies for hospital outpatient 
care measures, for a variety of reasons. For example, one commenter 
pointed out that there is evidence that patients diagnosed with AMI, 
and who have no contraindications for receiving particular medications, 
have a better outcome if they receive aspirin and beta blockers within 
a short time of presenting to the hospital. However, there is no 
evidence of better outcomes

[[Page 68196]]

for patients who receive aspirin when they present in an emergency 
department with chest pain, but are diagnosed with some condition other 
than heart attack and are sent home. Therefore, these commenters 
believe that CMS should proceed with care in taking these measures into 
account in the outpatient setting only after a thorough, scientific 
review to establish the application of the measures to outpatient care. 
One commenter specifically recommended that CMS should not proceed with 
expanding quality reporting into the hospital outpatient setting in any 
manner without a thorough scientific review conducted by such 
organizations as the National Quality Forum (NQF). The commenter noted 
that the NQF has endorsed the 21 hospital-based inpatient quality 
measures only for assessing quality of care in the inpatient setting, 
not for use in the hospital outpatient setting. Some commenters were 
concerned that additional outpatient hospital-specific measures could 
result in a greatly increased administrative burden, due to the volume 
of services in the outpatient setting that is much greater than the 
inpatient setting. Other commenters asked that outpatient quality and 
cost of care measures conform to standards of clinically appropriate 
care as established by peer-reviewed literature or professional 
consensus, be sufficiently flexible to allow access to new technology 
and devices, and be reviewed and updated periodically. They thought 
that when providers met a particular measure, it should be removed to 
reduce the reporting burden.
    MedPAC agreed that certain of the IPPS measures, such as provision 
of aspirin on arrival to a patient with AMI, could conceptually be 
employed for evaluating outpatient quality. However, MedPAC also 
advised that additional analysis may be necessary in order to ensure 
that these measures apply in the outpatient hospital setting. MedPAC 
also expressed a preference that CMS seek the authority to move beyond 
pay-for-reporting toward pay-for-performance, so that payment updates 
depend on empirical evidence of outcomes from the quality data, not 
merely on whether the data are submitted.
    Response: We appreciate the many thoughtful comments that we 
received on our proposal. We continue to believe that the statute 
permits us to provide a differential payment adjustment under the OPPS 
for quality reporting, consistent with our broad authority under 
section 1833(t)(2)(E) of the Act to provide an adjustment to ensure 
that payments are equitable. As we explained in the proposed rule, it 
is inequitable for hospitals providing poorer quality care that may 
result in the provision of more health services to Medicare 
beneficiaries in the hospital outpatient department to be in a position 
to receive higher payments from the OPPS for that episode of care, a 
result more in keeping with a fee-for-service payment system that 
provides payments for services without a focus on quality. The rapid 
spending growth in the OPPS is primarily due to brisk growth in the 
intensity and utilization of services, rather than general price or 
enrollment changes. This growth has occurred in an OPPS payment 
environment that has not yet focused on accounting for high quality 
care that improves the health of Medicare beneficiaries. We believe 
that the OPPS must look forward, and that future OPPS spending should 
be directed in the most efficient manner possible toward higher quality 
services. A continued lack of focus on the quality and value is not 
desirable for the program over the upcoming years. Specifically, we 
believe we have the statutory authority to provide a differential 
update based on quality reporting in the OPPS as we proposed. While we 
acknowledge that the IPPS RHQDAPU program is based in part on a DRA 
provision, the law does not preclude the Secretary from using his other 
statutory authorities to ensure that other services paid by Medicare, 
such as the outpatient hospital services paid under the OPPS, are of 
appropriately high quality.
    CMS' shift across payment systems to quality-based payment reform 
is an evolutionary process. On the hospital inpatient side, we began 
with linking the IPPS annual payment update to reporting on 10 quality 
measures, and we now have expanded the measure set for inpatient 
hospital reporting in FY 2007. In the DRA, Congress mandated that DHHS 
develop a plan for implementation of hospital value-based purchasing 
beginning with FY 2009. While the plan specifically focuses on the 
inpatient setting, moving toward pay for reporting in the hospital 
outpatient setting as we proposed is a logical next step. We believe it 
is very valuable for hospitals and CMS to gain as much experience as 
possible with all aspects of quality reporting with a focus on 
ultimately enhancing value for Medicare.
    As we discussed in detail in our proposal, we proposed as an 
initial step in the program's movement toward value-based purchasing to 
reduce the update to the CY 2007 OPPS conversion factor by 2.0 
percentage points for those hospitals that are required to report 
quality data under the IPPS RHQDAPU quality reporting program and fail 
to meet the requirements for receiving the full FY 2007 IPPS payment 
update. We appreciate the perspective of the commenters who 
acknowledged that this initial step was a sensible progression and 
agreed that the proposal would provide an extra incentive for hospital 
quality reporting that is an effective avenue to hospital 
accountability and quality improvement. We also explained that this 
proposal was only the first phase of implementing a quality reporting 
program in the OPPS, which would eventually expand to encompass 
reporting by all hospitals paid under the OPPS and refinement of 
quality measures to include those specific to hospital outpatient 
services.
    In contrast, however, we acknowledge that many commenters expressed 
their belief that quality performance in the outpatient setting could 
only be fairly and accurately assessed through the reporting of quality 
measures that are specific to outpatient hospital care by all hospitals 
paid under the OPPS. We agree that the current inpatient quality 
measures have some limitations as proxies for the quality of outpatient 
hospital care, in particular, their use to assess what constitutes 
effective treatment for different patient populations. The inpatient 
measures have been developed and refined for those patients who are 
admitted as hospital inpatients, and those patients may differ in 
several ways, including the severity of their illnesses, from hospital 
outpatients. We agree with commenters who believe that hospitals should 
be held accountable for the quality of their outpatient hospital 
services through measures that are specific to that care. Throughout 
the development of the IPPS quality measures, we have highly valued 
stakeholder input in the measure selection and refinement processes. We 
hope they continue to contribute vital input into the OPPS RHQDAPU 
quality reporting program, as we seek to create a bridge based on 
quality in the OPPS between the care setting and the payment setting. 
We do not intend to implement a quality reporting program linked to the 
OPPS annual update that is based on quality reporting that does not 
conceptually and practically reflect this vital link.
    While the DRA-mandated hospital value-based purchasing plan only 
requires CMS to design a plan for the inpatient hospital setting, as 
part of that work we are also considering issues

[[Page 68197]]

related to the implementation of quality reporting in the hospital 
outpatient setting. We see extension of the focus on quality to 
outpatient hospital services, many of which were inpatient services 
until recently, as a logical progression. Most importantly, we believe 
that implementing a payment adjustment would serve as an important 
milestone to signal the program's emerging focus on quality services 
that provide significant benefits to the health of Medicare 
beneficiaries.
    We agree with the commenters that assessment of hospital outpatient 
performance would ultimately be most appropriately based on reporting 
of hospital outpatient measures developed specifically for this 
purpose. Public reporting of specific outpatient hospital quality 
measures requires not only having developed, accepted measures, but 
also having in place the infrastructure for data collection and 
reporting. To reach the point where an outpatient hospital measure is 
collected and reported, based on our experience with developing the 
IPPS measures, multiple steps are involved. For a single measure, these 
steps include developing the measure, obtaining stakeholder 
endorsement, vetting the measure with appropriate organizations, 
engaging vendors and providing a vehicle for chart reviews to support 
reporting, testing of the Web site display, and then beginning data 
collection. From the start of actual data collection, given the time 
period allowed for submission of data and the time it takes to preview 
and ultimately generate a usable report, it would take at least one 
year before the measure could be reported.
    CMS has built strong and productive working relationships with many 
organizations, including the Joint Commission on Accreditation of 
Healthcare Organizations, the NQF, Hospital Quality Alliance, and 
others through our IPPS measure development experience. We would hope 
these relationships continue in our move to develop outpatient hospital 
quality measures for reporting. We also would seek to minimize the 
reporting burden on hospitals through close collaboration with the 
hospital industry to develop appropriate measures and an efficient data 
collection methodology. Some commenters recommended that some of the 
current inpatient hospital measures could be adapted to provide 
information specifically regarding outpatient hospital care. However, 
whether we adapt existing measures or develop new ones, we would need 
to engage in the same development and infrastructure activities. We 
have already begun to take a more systematic approach to the 
development of hospital outpatient measures, and we plan to accelerate 
our timetable significantly during CY 2007. We appreciate the specific 
suggestions of commenters regarding measure development for hospital 
outpatient care, and we welcome ongoing public input in this area.
    We have concluded that the most appropriate course at this point is 
to implement the OPPS quality update reporting program based on 
measures specifically developed to characterize the quality of hospital 
outpatient care. We believe the process will require 2 years before 
quality measure data are available. Given our concerns about the 
increasing growth in OPPS spending without concern for the value of the 
services, we do not believe it would be appropriate to delay focusing 
on the quality of hospital outpatient services beyond the minimum of 2 
years required for the development and implementation of these 
measures.
    We agree with those commenters who pointed out that implementation 
of the OPPS RHQDAPU program as proposed for CY 2007 would mean that 
hospitals could not have made decisions regarding their participation 
in the IPPS quality reporting program with full knowledge of the 
effects of their participation on their OPPS update. While 
implementation of the OPPS RHQDAPU program in CY 2008 based on 
hospitals' participation in the IPPS RHQDAPU would be possible because 
hospitals would have the opportunity to make decisions knowing the 
consequences of their participation, we believe that the quality of 
hospital outpatient services would be most appropriately and fairly 
rewarded through the reporting of quality measures developed 
specifically for application in the hospital outpatient setting. 
Therefore, we are delaying implementation of the OPPS RHQDAPU program 
until CY 2009, when we will implement a 2.0 point reduction to the OPPS 
conversion factor update for those hospitals that do not meet the 
specific requirements of the CY 2009 OPPS RHQDAPU program. The CY 2009 
program will be based upon CY 2008 hospital reporting of effective 
measures of the quality of hospital outpatient care that have been 
carefully developed and evaluated, and endorsed as appropriate, with 
significant input from stakeholders.
    We have revised proposed Sec.  419.43(h) to reflect this new 
effective date and we are adopting it as revised in this final rule 
with comment period. We also note that in the CY 2008 OPPS proposed 
rule, we may further refine our approach under the OPPS RHQDAPU 
program.
    We continue to believe that it is not only appropriate but 
necessary to require that hospitals must fully comply with the OPPS 
RHQDAPU program requirements to receive OPPS payment that reflects the 
full CY 2009 update to the conversion factor. We believe that ensuring 
that Medicare beneficiaries receive the care they need and that such 
services are of appropriately high quality are the necessary initial 
steps to incorporating value-based purchasing into the OPPS. We seek to 
encourage care that is both efficient and of high quality in the 
hospital outpatient department. We plan to work quickly and 
collaboratively with the hospital community to develop and implement 
quality measures for the OPPS that are fully and specifically 
reflective of the quality of hospital outpatient services.

XX. Promoting Effective Use of Health Information Technology

    We recognize the potential for health information technology (HIT) 
to facilitate improvements in the quality and efficiency of health care 
services. One recent RAND study found that broad adoption of electronic 
health records could save more than $81 billion annually and, at the 
same time, improve quality of care.\5\ The largest potential savings 
that the study identified was in the hospital setting because of 
shorter hospital stays promoted by better coordinated care; less 
nursing time spent on administrative tasks; better use of medications 
in hospitals; and better utilization of drugs, laboratory services, and 
radiology services in hospital outpatient settings. The study also 
identified potential quality gains through enhanced patient safety, 
decision support tools for evidence-based medicine, and reminder 
mechanisms for screening and preventive care. Despite such large 
potential benefits, the study found that only about 20 to 25 percent of 
hospitals have adopted HIT systems.
---------------------------------------------------------------------------

    \5\ RAND News Release: Rand Study Says Computerizing Medical 
Records Could Save $81 Billion Annually and Improve the Quality of 
Medical Care, September 14, 2005, available at: http://rand.org/news/press.05/09.14.html.
---------------------------------------------------------------------------

    It is important to note the caveats to the RAND study. The 
projected savings are across the health care sector, and any Federal 
savings would be a portion of the total savings. In addition, there are 
significant assumptions made in the RAND study. National savings are 
projected in some cases based on one or two small studies. Also, the 
study assumes patient compliance, in the form

[[Page 68198]]

of participation in disease management programs and following medical 
advice. For these reasons, extreme caution should be used in 
interpreting these results.
    In his 2004 State of the Union Address, President Bush announced a 
plan to ensure that most Americans have electronic health records 
within 10 years.\6\ One part of this plan involves developing voluntary 
standards and promoting the adoption of interoperable HIT systems that 
use these standards. The 2007 Budget states that ``The Administration 
supports the adoption of health information technology (IT) as a normal 
cost of doing business to ensure patients receive high quality care.''
---------------------------------------------------------------------------

    \6\ Transforming Health Care: The President's Health Information 
Technology Plan, available at: http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html.
---------------------------------------------------------------------------

    Over the past several years, CMS has undertaken several activities 
to promote the adoption and effective use of HIT in coordination with 
other Federal agencies and with the Office of the National Coordinator 
for Health Information Technology. One of those activities is promotion 
of data standards for clinical information, as well as for claims and 
administrative data. In addition, through our 8th Scope of Work 
contract with the QIOs, we are offering assistance to hospitals on how 
to adopt and redesign care processes to effectively use HIT to improve 
the quality of care for Medicare beneficiaries, including computerized 
physician order entry (CPOE) and bar coding systems. Finally, our 
Premier Hospital Quality Incentive Demonstration provides additional 
financial payments for hospitals that achieve improvements in quality, 
which effective HIT systems can facilitate.
    We are considering the role of interoperable HIT systems in 
increasing the quality of hospital services while avoiding unnecessary 
costs. As noted above, the Administration supports the adoption of HIT 
as a normal cost of doing business. While payments under the OPPS do 
not vary depending on the adoption and use of HIT, hospitals that 
leverage HIT to provide better quality services may more efficiently 
reap the reward of any resulting cost savings. In addition, the 
adoption and use of HIT may contribute to improved processes and 
outcomes of care, including shortened hospital stays and the avoidance 
of adverse drug reactions.
    In the proposed rule, we sought comments on our statutory authority 
to encourage the adoption and use of HIT. We also sought comments on 
the appropriate role of HIT in any value-based purchasing program, 
beyond the intrinsic incentives of the OPPS, to provide efficient care, 
encourage the avoidance of unnecessary costs, and increase quality of 
care. In the proposed rule, we did not propose adding adoption of HIT 
to the Medicare hospital conditions of participation. However, we 
solicited comments on promotion of the use of effective HIT through 
hospital conditions of participation, perhaps by adding a requirement 
that hospitals use HIT that is compliant with and certified in its use 
of the HIT standards adopted by the Secretary. We anticipate that the 
American Health Information Community will provide advice to the 
Secretary on these issues.
    We received 13 responses to the proposed rule on this section. 
Below is a summary of the comments within each response addressing: (1) 
CMS' statutory authority and use of our conditions of participation to 
encourage adoption of effective HIT; (2) the role that HIT should play 
in value-based purchasing; and (3) the importance of interoperability 
standards in promoting the adoption of HIT. In addition to these areas 
in which we sought comments, we also received several comments on the 
challenges of implementing HIT, which were particularly focused on 
barriers such as the high cost of implementation.
    Comments: Some commenters addressed CMS' statutory authority to 
encourage adoption of effective HIT. One commenter referenced CMS' 
previous use of statutory authority to promulgate exceptions under the 
physician self-referral law as an example of the agency's authority to 
promote the adoption of HIT. Another commenter stated that CMS does not 
have the statutory authority to promote adoption of HIT and, therefore, 
should concentrate on other mechanisms, such CMS' demonstrations 
authority to encourage HIT adoption.
    Several commenters addressed CMS' idea of promoting the adoption of 
HIT through CMS conditions of participation. Some of the commenters 
were in favor of including adoption of HIT in conditions of 
participation. One commenter suggested making modifications to existing 
conditions of participation in lieu of creating new conditions of 
participation to accommodate adoption of HIT. Many commenters opposed 
including the adoption of HIT in the conditions of participation. 
Commenters opposed to including HIT implementation within conditions of 
participation characterized the proposal as creating an ``unfunded 
mandate.''
    Many commenters provided feedback on the proper role of HIT within 
a value-based purchasing system. The majority of commenters noted that 
adoption of HIT can lead to improved quality, enhanced patient safety, 
and increased efficiency. Many commenters emphasized that HIT can 
reduce the burden associated with quality reporting. One commenter 
stated that the foundation of HIT adoption should support the aims 
outlined within the IOM's ``Crossing the Quality Chasm Report'': 
safety, effectiveness, patient-centeredness, timeliness, efficiency, 
and equity. Another commenter suggested that CMS could advance its 
quality agenda by investing in the development of algorithms for the 
calculation of quality measure scores.
    Most commenters stated that a value-based purchasing system should 
emphasize process and outcomes measures, rather than structural 
measures such as the use of HIT tools like computerized physician order 
entry. However, two commenters stated that use of HIT should be 
included as a structural measure for any value-based purchasing system.
    Several commenters addressed the costs associated with HIT 
implementation. Several commenters stated that HIT is very costly to 
implement and felt strongly that implementation of HIT should be a 
shared expense between providers, purchasers, and payers. Some 
commenters felt that incentives could aid providers by reducing the 
cost burden and suggested that direct Medicare payment for HIT would 
most effectively encourage its adoption.
    Several commenters addressed the importance of interoperability 
standards for HIT. Many commenters noted that interoperability 
standards are a critical component of any HIT system and must include a 
standard set of policies, procedures, and standards for data collection 
and documentation. The commenters also noted the importance of having 
interoperability standards that are publicly available and non-
proprietary. One commenter suggested that HHS and AHIC should provide 
modern terminology to guide the adoption of interoperability standards, 
such as those identified in the Consolidated Health Informatics (CHI) 
and the SNOMED-CT[supreg], adopted by CHI and approved by the National 
Committee on Vital and Health Statistics. In addition to 
interoperability standards, one commenter stated that a rigorous 
quality assurance process that addresses strict adherence to 
interoperability standards should be required by third party 
certification.

[[Page 68199]]

    One commenter strongly supported the role of both AHIC and the 
Ambulatory Quality Alliance-Hospital Quality Alliance Steering 
Committee in promoting the adoption of HIT. Another commenter commended 
CMS on promoting adoption of HIT by ``promulgating regulatory 
protections under the physician self-referral and Anti-Kickback 
Statutes for donations related to electronic medical records.''
    Response: We thank all commenters for their thoughtful and valuable 
discussion of the issues. In the HIT section of the preamble to the 
proposed rule, we recognized the potential for effective HIT to 
facilitate improvements in the quality and efficiency of health care 
services. We also pointed out CMS' promotion of the adoption and 
effective use of HIT in coordination with other Federal agencies and 
the Office of the National Coordinator for Health Information 
Technology. Here, we will discuss three initiatives that we are 
emphasizing to promote the effective use of HIT, in light of the 
comments we received: (1) Value-based purchasing, (2) the recent CMS 
and OIG final rules regarding the donation of certain HIT, and (3) 
infrastructure and interoperability standards.
    We continue to explore the implementation of value-based purchasing 
payment system reforms because we believe that, among other advantages, 
value-based purchasing can encourage hospitals to invest in activities, 
such as effective HIT, that have the potential to improve quality and 
decrease unnecessary costs. However, linking a portion of Medicare 
payments to valid measures of quality and effective use of resources 
could give hospitals more direct incentives to implement innovative 
ideas and approaches that may result in improved value of care. We 
agree with the commenters that noted that the use of effective HIT 
could increase quality, efficiency, and patient safety. We also agree 
with the commenters that noted that effective use of HIT can be used to 
decrease the burden of reporting to value-based purchasing programs. 
However, we disagree with the commenters that recommended direct 
government funding of HIT. As stated in the President's 2007 Budget, 
``the Administration supports the adoption of [HIT] as a normal cost of 
doing business to ensure patients receive high quality care.''
    Commenters noted that multiple stakeholders in the health care 
system, including purchasers and payers, benefit from provider adoption 
and use of effective HIT and should share in the cost. CMS and OIG have 
recently issued final rules to allow hospitals and other health care 
providers under some circumstances to donate electronic prescribing and 
electronic health records technology to physicians and others without 
running afoul of the Stark (physician self-referral) and anti-kickback 
statutes. We believe that these rules facilitate the adoption of HIT by 
physicians and other health care providers who might otherwise have 
been unable or unwilling to invest in the technology.
    We also believe that these regulatory changes help to stimulate the 
adoption of effective HIT, and that, as HIT use spreads, the benefits 
relative to the costs of implementation may increase for all 
stakeholders.
    The majority of commenters pointed out that the current lack of HIT 
infrastructure, including lack of interoperability standards, is a 
major obstacle to adoption and effective use of HIT. To address the 
lack of infrastructure, the Secretary has undertaken a national 
strategy that calls for Federal agencies to collaborate with private 
stakeholders in the development of architecture, standards, 
certification processes, and methods of governance to facilitate the 
adoption of effective HIT. In September 2005, the Secretary selected 16 
commissioners to serve on the American Health Information Community 
(AHIC or Community), which is a federally chartered collaborative forum 
of private and public interests charged with advising the Secretary on 
how to make health information digital and interoperable. The goals of 
the Community include immediate access to vital medical information at 
the point of care, privacy protection, better data for research, and 
overall cost savings. The work of the Community has been divided among 
six workgroups: (1) The Electronic Health Records Workgroup, (2) the 
Chronic Care Workgroup, (3) the Consumer Empowerment Workgroup, (4) the 
Biosurveillance Workgroup, (5) the Confidentiality, Privacy, and 
Security Workgroup, and (6) the Quality Workgroup. The AHIC Workgroups 
have made recommendations, as their initial ``breakthroughs,'' 
pertaining to: an electronic medication summary and registration 
history; secure messaging capabilities for individuals with chronic 
disease; biosurveillance monitoring; and, through secure means, 
broadening the availability and access to current and historical 
laboratory results and interpretations. More information about the 
Community is available at: http://www.hhs.gov/healthit/ahic.html.
    In conclusion, we are not at this time requiring adoption of 
certified, interoperable HIT as a part of the Medicare conditions of 
participation. Rather, we are reserving judgment on the imposition of 
such a requirement and will continue to research the feasibility of 
doing so. We may revisit this issue in the CY 2008 OPPS proposed rule 
or in another rulemaking proceeding.

XXI. Health Care Information Transparency Initiative

    The United States (U.S.) faces a dilemma in health care. Although 
the rate of increase in health care spending slowed last year, costs 
are still growing at an unsustainable rate. The U.S. spends $1.9 
trillion on health care, or 16 percent of the gross domestic product 
(GDP). By 2015, projections are that health care will consume 20 
percent of GDP. The Medicare program alone consumes 3.4 percent of the 
GDP; by 2040, it will consume 8.1 percent of the GDP, and by 2070, 14 
percent of the GDP.
    Part of the reason health care costs are rising so quickly is that 
most consumers of health care--the patients--are frequently not aware 
of the actual cost of their care. Health insurance shields them from 
the full cost of services, and they have only limited information about 
the quality and costs of their care. Consequently, consumers do not 
have the incentive or means to carefully shop for providers offering 
the best value. Thus, providers of care are not subject to the 
competitive pressures that exist in other markets for offering quality 
services at the best possible price. Reducing the rate of increase in 
health care prices and avoiding health services of little value could 
help to stem the growth in health care spending, and potentially reduce 
the number of individuals who are unable to afford health insurance. 
Part of the President's health care agenda is to expand Health Savings 
Accounts (HSAs), which would provide consumers with greater financial 
incentives to compare providers in terms of price and quality, and 
choose those that offer the best value.
    In order to exercise those choices, consumers must have accessible 
and useful information on the price and quality of health care items 
and services. Typically, health care providers do not publicly quote or 
publish their prices. Moreover, list prices, or charges, generally 
differ from the actual prices negotiated and paid by different health 
plans. Thus, even if consumers were financially motivated to shop for 
the best price, it would be very difficult at the current time for them 
to access usable information.

[[Page 68200]]

    For these reasons, DHHS is launching a major health care 
information transparency initiative in 2006. This effort builds on 
steps taken by CMS to make quality and price information available. For 
example, Medicare has provided unprecedented information about drug 
prices in the Medicare drug benefit, and is now adding to these efforts 
in other areas. We recently posted Medicare payment information for 
common elective procedures and other common admissions for all 
hospitals by county on our Web site at http://www.cms.hhs.gov/HealthCareConInit/01_Overview.asp#TopOfPage. We also recently posted 
geographically-based Medicare payment information for common elective 
procedures for ambulatory surgery centers on our Web site at http://www.cms.hhs.gov/HealthCareConInit/03_ASC.asp. We will post similar 
information for common hospital outpatient and physician services this 
fall.
    In addition, a number of tools providing usable health care 
information are already available to Medicare beneficiaries. Consumers 
can access ``Compare'' Web sites through http://www.medicare.gov where 
they can evaluate important aspects of their health care options for 
care at a hospital, nursing home, home health agency, and dialysis 
facility, as well as compare their costs and coverage when choosing a 
prescription drug plan.
    CMS is developing a transparency initiative with the goals of 
providing more comprehensive information on quality and costs, 
including more complete measures of health outcomes, satisfaction, and 
volume of services that matter to consumers, and more comprehensive 
measures of costs for entire episodes of care, not just payments for 
particular services and admissions. We intend for the project to 
combine public and private health care data to provide cost and quality 
of care information at the physician and hospital levels. Quality, 
cost, pricing, and patient information will be reported to consumers 
and purchasers of health care in a meaningful and transparent way. In 
addition, we anticipate the project will provide a national template 
for performance measures and a payment structure that aligns payment 
and performance.
    The comments we received on our transparency initiative and our 
responses are summarized below.
    Comment: All commenters supported the concept of providing useful 
information for consumers and patients on the price and quality of care 
delivered in the outpatient setting. However, many commenters also 
noted the complexity of such information, particularly price and cost 
data, and identified issues that would need to be addressed when 
determining what information is most helpful and the manner in which it 
should be given to consumers.
    In particular, commenters noted that (1) the price of services 
varies by patient needs and services, (2) hospital costs also include 
their public service role, (3) physician services are not included in 
the hospital bill, and (4) hospital prices would vary based on the 
insurance status of the patient. The commenters suggested that price 
information should be easy to understand and use, easy to access, use 
common definitions and language, and explain the factors that affect 
prices. Several commenters also described their proposals for making 
such information more readily available through state and insurer 
mandates and hospital and Federal research efforts to identify the most 
useful price information. Several commenters also noted that price and 
quality information should be released together.
    Response: We agree that price information is complex and that the 
factors that affect price noted by the commenters should be considered 
when determining what information to release and the manner in which it 
is provided. For inpatient services, we released Medicare payment 
information for common conditions, and we plan to do so for outpatient 
services later this fall. This type of information provides 
beneficiaries and their families with information on their potential 
out-of-pocket costs. Another useful way to describe costs may be to 
provide information on the total costs for a course of treatment 
(beyond just the inpatient stay) for an episode of care (potentially 
encompassing all providers and over time for a specific condition). 
Consumers may also want information about the quality of care across 
the episode. Because some services delivered in the outpatient setting 
are also delivered in ambulatory surgical centers and physicians' 
offices, we also may consider comparisons across settings in the 
future.
    We also agree that information on price should be easy to use and 
access, and that it is important to continue research on the best way 
to provide such information to consumers. We have been posting 
information on the quality of care for several settings, including 
hospitals, nursing homes, dialysis facilities, Medicare Advantage 
plans, and Part D plans. Regarding the Part D information, we have 
created an interactive tool which provides beneficiaries an 
unprecedented level of detail on the availability of their drugs and 
potential cost liability for plans in their region. We anticipate using 
our experience with these tools and working with others to develop 
useful tools for displaying information on outpatient services.
    We are grateful for the support for our efforts and will welcome 
proposals for providing consumers and patients useful information on 
price and quality.
    Comment: Several commenters suggested that CMS work through the AQA 
and Hospital Quality Alliance efforts, along with the joint steering 
committee charged with harmonizing hospital and physician measurement--
the Quality Alliance Steering Committee--to identify the most useful 
price and quality measures for the outpatient settings.
    Response: We strongly support the AQA and HQA efforts, and believe 
that such collaboration is critical to the success of transparency. To 
the extent these organizations, as well as others, such as the National 
Quality Forum, reach consensus regarding price or quality measures for 
outpatient settings we would look to their efforts to inform ours.
    Comment: One commenter stated that in addition to making sure the 
measures and the process are useful, it is critical to make sure the 
data, particularly claims, are consistent across settings. The 
commenter noted the need to update data standards to reflect the 
contents of 21st century health records, including moving to ICD-10-CM 
and using other standards endorsed by the National Committee on Vital 
and Health Statistics (NCVHS).
    Response: We agree that it is critically important for the 
information underlying these price and quality measures to be as 
uniform and accurate as possible. As directed by the President's 
Executive Order, we are currently engaged in numerous department 
initiatives to identify and endorse terminology and messaging standards 
and to support a certification process for electronic health records. 
We also support movement towards the ICD-10-CM coding system. As 
consumers, patients, and providers become increasingly engaged in the 
use of health care price and quality information this will become ever 
more important.
    Comment: One commenter noted that the length of time used to 
calculate costs and quality is critical. The commenter stated that the 
outcome of a service may take a long time to manifest, sometimes even 
longer than a year, so that the

[[Page 68201]]

length of time used should be considered.
    Response: We recognize that the length of time in which patient 
outcomes manifest may vary. We believe it will be important, 
particularly when assessing the cost and quality of broad episodes of 
care to vary the episode length depending on the patterns of care 
specific to the condition.

XXII. Additional Quality Measures and Procedures for Hospital Reporting 
of Quality Data for the FY 2008 IPPS Annual Payment Update

A. Background

    Section 5001(a) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 
109-171) sets out new requirements for the IPPS Reporting Hospital 
Quality Data for Annual Payment Update (RHQDAPU) program. The IPPS 
RHQDAPU program was established to implement section 501(b) of the 
Medicare Prescription Drug, Improvement and Modernization Act of 2003 
(MMA) (Pub. L. 108-173). It builds on our ongoing voluntary Hospital 
Quality Initiative which is intended to empower consumers with quality 
of care information to make more informed decisions about their health 
care while also encouraging hospitals and clinicians to improve the 
quality of care.
    Section 5001(a) of Public Law 109-171 revises the mechanism used to 
update the standardized amount for payment for hospital inpatient 
operating costs. New sections 1886(b)(3)(B)(viii)(I) and 
1886(b)(3)(B)(viii)(II) of the Act provide that the payment update for 
FY 2007 and each subsequent fiscal year will be reduced by 2.0 
percentage points for any ``subsection (d) hospital'' that does not 
submit certain quality data in a form and manner, and at a time, 
specified by the Secretary. Under sections 1886(b)(3)(B)(viii)(III) and 
1886(b)(3)(B)(viii) (IV) of the Act, we must expand the ``starter set'' 
of quality measures that we have used since FY 2005, and to begin to 
adopt the baseline set of performance measures as set forth in a 2005 
report issued by the Institute of Medicine of the National Academy of 
Sciences (IOM) under section 238(b) of the MMA, effective for payments 
beginning with FY 2007. The 2005 IOM report's ``baseline'' quality 
measures include Hospital Quality Alliance (HQA)-approved clinical 
quality measures, the Hospital Consumer Assessment of Healthcare 
Providers and Systems (HCAHPS) patient perspective survey, and three 
structural measures. The structural measures are: (1) Implementation of 
computerized provider order entry for prescriptions, (2) staffing of 
intensive care units with intensivists, and (3) evidence-based hospital 
referrals. These measures originate from the Leapfrog Group's original 
``three leaps,'' and are part of the NQF's 30 safe practices.
    In 2002, the Secretary of HHS initiated a partnership with several 
collaborators intended to promote hospital quality improvement and 
public reporting of hospital quality information. This collaboration is 
known as the Hospital Quality Alliance (HQA). The collaborators include 
the American Hospital Association, the Federation of American 
Hospitals, the Association of American Medical Colleges, the Joint 
Commission on Accreditation of Healthcare Organizations (JCAHO), the 
National Quality Forum (NQF), the American Medical Association, the 
Consumer-Purchaser Disclosure Project, the AARP, the American 
Federation of Labor-Congress of Industrial Organizations (AFL-CIO), the 
Agency for Healthcare Research and Quality (AHRQ), as well as CMS, 
Quality Improvement Organizations (QIOs), and other stakeholders who 
share a common interest in reporting on hospital quality. The HQA has 
been proactive in making performance data on hospitals accessible to 
the public, thereby improving patient care.
    The RHQDAPU program, however, is distinct from the HQA (formerly 
known as the National Voluntary Hospital Reporting Initiative). 
Hospitals participate in the HQA on an entirely voluntary basis. 
Participation in HQA has no bearing on payment under Medicare or any 
other Federal program. The RHQDAPU program is a CMS program that ties 
quality data reporting to payment under the IPPS. In some ways, the HQA 
can be seen as a testing ground for a quality measure before CMS adopts 
it for purposes of the RHQDAPU program. To date, all of the quality 
measures CMS has adopted for purposes of the RHQDAPU had previously 
been for HQA reporting. We note, however, that HQA adoption is not a 
legal prerequisite for CMS to adopt a measure for purposes of the 
RHQDAPU program.
    In the FY 2007 IPPS final rule, we began to implement the new IPPS 
RHQDAPU program requirements by adding 11 HQA-approved measures to our 
10-measure ``starter set'' of quality measures, for purposes of the FY 
2007 update (71 FR 48031 through 48037).
    Under section 1886(b)(3)(B)(viii)(V) of the Act, for payments 
beginning with FY 2008, we are required to add other measures that 
reflect consensus among affected parties and, to the extent feasible 
and practicable, we must include measures set forth by one or more 
national consensus building entities.
    Commenters on the FY 2007 IPPS proposed rule requested that we 
notify the public as far in advance as possible of any proposed 
expansions of the measure set and program procedures in order to 
encourage broad collaboration and to give hospitals time to prepare for 
any anticipated changes. Other commenters requested that we adopt 
additional quality measures and that we do so as soon as feasible. For 
example, several commenters urged that we adopt the HCAHPS patient 
survey as a part of the IPPS RHQDAPU program, while others suggested 
that we adopt more of the IOM measures as well as more outcome 
measures, including mortality measures that were not included in the 
2005 IOM report's ``baseline'' quality measures. In response to these 
comments and as part of our continuing efforts to strengthen the IPPS 
RHQDAPU program, in the CY 2007 OPPS proposed rule, we sought comments 
on this proposal to expand, for FY 2008, the measurement set beyond 
those measures we adopted for purposes of the FY 2007 update. This 
proposed expanded set would further broaden the scope of the IPPS 
RHQDAPU program by including the HCAHPS patients' perspectives of care 
measures as well as surgical care and mortality outcome measures. We 
received a number of comments in response to our proposal. These 
comments are discussed below.
    Comment: A majority of the commenters appreciated that CMS has 
proposed measures for FY 2008 that have already been adopted as part of 
the HQA's effort to promote public reporting of hospital data. Also, 
commenters recommended that CMS continue to work with HQA and that CMS 
align its choices of measures and link payment with the measures chosen 
by HQA to provide a public accountability for quality. The commenters 
suggested that this alignment will also reinforce the importance of 
public transparency on quality to help to focus quality improvement 
efforts on identified high priority care areas.
    Response: We strongly value our association with the HQA, which was 
established as a public-private collaboration to promote voluntary 
hospital public reporting on quality of care. We plan to continue to 
work closely with HQA on the choice of measures publicly reported on 
Hospital Compare. Additionally, we will

[[Page 68202]]

continue to focus efforts on measures adopted by the HQA.
    Comment: A majority of the commenters applauded and expressed 
support for CMS efforts to establish the measures hospitals will be 
expected to report under the IPPS RHQDAPU program early enough for 
hospitals to put the proper data collection processes in place.
    Response: We appreciate these comments as we recognize the 
importance of communications to hospitals. CMS will continue to provide 
information as early as possible on the measures hospitals that will be 
used for the IPPS RHQDAPU program. We also look forward to commenters' 
continued support as we expand the set of measures for the program.
    Comment: One commenter supported the expanded FY 2008 measurement 
set, but urged CMS to also add the structural measures that were 
included in the 2005 IOM report ``Performance Measurement: Accelerating 
Improvement.''
    Response: At this time we are not adopting the three structural 
measures recommended by the Leapfrog Group. As we continue to expand 
the set of measures under the IPPS RHQDAPU program, we will further 
evaluate and consider these structural measures.
    Comment: One commenter supported the HQA and its work to implement 
NQF-endorsed measures through a collaborative, public-private 
partnership. However, although the commenter believed that the HQA has 
been instrumental in advancing hospital performance reporting via the 
Hospital Compare Web site, the commenter did not believe that the HQA 
adhered to the same consensus-building process used by the NQF. The 
commenter viewed the roles of these two entities as distinct, though 
complementary.
    Response: We agree that the roles of the HQA and NQF are distinct. 
However, the NQF is represented on the HQA and the HQA has in principle 
and in practice agreed to only employ NQF-endorsed measures for public 
reporting. Therefore, all measures advanced by the HQA for public 
reporting have gone through the NQF consensus building process.
    Comment: One commenter suggested that there was a need to develop 
an infrastructure that would facilitate the efficient transmission and 
storage of data and to designate an oversight entity that is 
responsible for the infrastructure. The commenter recommended that CMS 
consult with healthcare stakeholders before determining where the 
quality data are housed.
    Response: We have a centralized information technology 
infrastructure in place for the transmission and storage of clinical 
data in support of our quality improvement initiatives. Clinical data 
are transmitted to the QIO Clinical Warehouse via QualityNet Exchange, 
a secure Web site. Access to data stored in the QIO Clinical Warehouse 
is limited to authorized parties. We solicit input from other 
healthcare stakeholders to facilitate the design and enhancements to 
this system.
    Comment: One commenter stated the current reporting of quality data 
is costly, the data definitions change quarterly, and it is difficult 
to use the validation process. The commenter recommended that because 
payments are based on the validation of the measures, CMS must 
absolutely ensure that the CDAC and QIOs interpret the data the same 
way.
    Response: The validation and appeal processes are posted on the 
QualityNet Web site under the Hospital/Data Validation tab. The 
Specifications Manual for National Hospital Quality Measures is updated 
routinely to stay with current medical practices. Hospitals should 
continue working with their QIOs in order to keep up with the most 
recent updates. The CDAC utilizes this same manual during validation 
for the re-abstraction of medical records. Modifications or 
clarifications in the manual are shared with hospitals, QIOs, and the 
CDAC concurrently in order to maintain a common abstraction knowledge 
base.
    We have devoted substantial resources to ensuring that the CDAC 
process is consistent, reliable and accurate.
    Comment: Two commenters suggested that CMS create a private-sector 
mechanism to leverage the reporting benefit the JCAHO is providing 
through its vendors, especially with respect to attention to the 
quality of the data.
    Response: CMS strongly values its collaborative relationship with 
the JCAHO and agrees the vendor community input is important. CMS is 
currently considering whether to form an advisory work group of vendors 
to work with our staff.
    Comment: One commenter did not oppose collecting of data on the 
proposed measures and publishing the measures for the public. However, 
the commenter opposed tying payment to the quality of the data during 
the initial phases of data collection of new measures sets. Also, the 
commenter opposed the proposed implementation of the new measure set 
because it does not give hospitals a transition period to collect data 
that will affect payments.
    Response: We thoroughly evaluate all measures before linking them 
to payment. We are using this rulemaking in addition to the IPPS 
rulemaking to establish additional measures in order to give hospitals 
advance notice and lead time to learn about the collection requirements 
of the new measures before linking them to payment. We note that the 
HQA will be collecting and reporting these new measures sets before 
hospitals begin reporting these measures for RHQDAPU purposes. For 
example, the HQA began collecting the SCIP-VTE 1 and SCIP-VTE 2 
measures in fourth quarter 2006, when they were first published in the 
HQA Specifications Manual for National Hospital Quality Measures. This 
allows hospitals three months to abstract and submit these measures 
before the first quarter of 2007, when they become IPPS RHQDAPU 
measures for purposes of the FY 2008 IPPS market basket update. 
Collection of SCIP Infection 1 and SCIP Infection 3 as RHQDAPU program 
measures for FY 2008 began third quarter of 2006. CMS believes the 
addition of SCIP-VTE 1, SCIP-VTE 2, and SCIP Infection 2 measures to 
the RHQDAPU measures beginning first quarter 2007 provides reasonable 
advance notice for hospitals.

B. Additional Quality Measures for FY 2008

1. Introduction
    In the CY 2007 OPPS proposed rule, we proposed to add the following 
categories to the FY 2008 IPPS RHQDAPU program measure set:
     HCAHPS Survey
    HCAHPS is also known as Hospital CAHPS[supreg] or the CAHPS[supreg] 
Hospital Survey. The HCAHPS survey is composed of the following 27 
questions:
    + 18 substantive questions that measure critical aspects of the 
hospital experience (communication with doctors; communication with 
nurses; responsiveness of hospital staff; cleanliness and quietness of 
hospital environment; pain management; communication about medicines; 
and discharge information).
    + 4 questions that direct patients to complete only those survey 
questions that apply to them.
    + 3 questions to be used to adjust the mix of patients across 
hospitals.
    + 2 questions that support Congressionally-mandated reports, the 
``National Healthcare Disparities Report,'' and the ``National 
Healthcare Quality Report.''
     Surgical Care Improvement Project (SCIP)
    + SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for 
surgery patient

[[Page 68203]]

    + SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery
    + SCIP Infection 2: Prophylactic antibiotic selection for surgical 
patients
     Mortality
    + Acute Myocardial Infarction 30-day mortality--Medicare patients
    + Heart Failure 30-day mortality--Medicare patients
    + Pneumonia 30-day mortality--Medicare patients
    We discuss these proposed measures in detail below.
2. HCAHPS Survey and the Hospital Quality Initiative
    We have partnered with another HHS agency, AHRQ, to develop HCAHPS. 
The intent of the HCAHPS initiative is to provide a standardized survey 
instrument and data collection methodology for measuring patients' 
perspectives of hospital care. While many hospitals currently collect 
information on patients' satisfaction with care, there is currently no 
national standard for collecting or publicly reporting this information 
that would enable valid comparisons to be made across hospitals. To 
make the appropriate comparisons to support consumer choice, we believe 
it is necessary to introduce a standard measurement approach. HCAHPS 
can be viewed as a core set of questions that can be combined with a 
broader, customized set of hospital-specific items. HCAHPS is intended 
to complement the data hospitals currently collect to support 
improvements in hospitals' internal customer services and quality 
related initiatives.
    Three broad goals have shaped HCAHPS. The survey is designed to 
produce data on the patients' perspective of care that allows objective 
and meaningful comparisons among hospitals on issues that are important 
to consumers. In addition, public reporting of the survey results is 
designed to create incentives for hospitals to improve their quality of 
care. Also, public reporting will serve to enhance public 
accountability in health care by increasing the transparency of the 
quality of hospital care provided in return for the public investment. 
With these goals in mind, the HCAHPS initiative has taken substantial 
steps to assure that the survey will be credible, useful, and 
practical.
    Throughout the HCAHPS development process, AHRQ and CMS have 
solicited and received a great deal of public input. AHRQ published a 
Federal Register notice that called for measures in July 2002 (67 FR 
48477) and we solicited input on drafts of the HCAHPS instrument and 
its implementation strategy (February 2003, June 2003, and December 
2003--68 FR 5889, 68 FR 38346, 68 FR 68087). In addition to the public 
comments received, results from a 3-State Pilot Study were used to 
reduce the pool of 66 survey questions to 25 questions.
    In addition to the development and review processes, we submitted 
the 25-item version of the HCAHPS instrument to the NQF for its review 
and endorsement through its consensus development process. The NQF is a 
voluntary consensus standard-setting organization established to 
standardize health care quality measurement and reporting. NQF 
endorsement represents the consensus of numerous health care providers, 
consumer groups, professional associations, purchasers, Federal 
agencies, and research and quality organizations. Following a thorough, 
multi-stage review process, HCAHPS was endorsed by the NQF board in May 
2005. In the process, NQF recommended a few modifications to the 
instrument. As a result of the recommendations of the NQF Consensus 
Development Process, questions regarding courtesy and respect were 
added to the survey. The NQF review committee believes that these 
questions are important to all patients, and may be particularly 
meaningful to patients who are members of racial and ethnic minority 
groups. Upon the recommendation of the NQF, we further examined the 
costs and benefits of the 27-item HCAHPS survey. This cost-benefit 
analysis of HCAHPS was conducted by Abt Associates, Inc. The report of 
this analysis can be found at http://www.cms.hhs.gov/HospitalQualityInits/downloads/HCAHPSCostsBenefits200512.pdf.
    We published a Federal Register notice soliciting comments on the 
draft 27-item HCAHPS Survey in November 2005 (70 FR 67476). The HCAHPS 
survey received approval by the Office of Management and Budget (OMB) 
on December 22, 2005.
    Shortly thereafter, we began final preparations for the voluntary 
national implementation (as a part of the Hospital Quality Initiative) 
with the support of the HQA. We also offered training sessions for 
hospitals self-administering the survey and survey vendors acting on 
behalf of hospitals in February and April 2006. Since HCAHPS was a new 
initiative, we decided that it was critical to hospitals, survey 
vendors, and CMS to acquire first-hand experience with data collection, 
including sampling and data submission to the QualityNet Exchange, 
before we collected data for public reporting. For hospitals 
participating in the national implementation of HCAHPS on October 1, 
2006, we required participation in a short dry run period of at least 
one month. A hospital could choose to sample and survey discharges in 
April, May, and/or June 2006. Data from this ``dry run'' are not 
publicly reported.
    National implementation began in October 2006 for this first set of 
hospitals and survey vendors that are participating in the HCAHPS 
voluntary initiative. The initial data collection covers 9 months of 
patient discharges (October 2006 through June 2007). Hospital results 
will be publicly reported on the CMS Hospital Compare Web site (http://www.hospitalcompare.hhs.gov). After the initial implementation, the Web 
site will contain 12 months of HCAHPS data and will be updated 
quarterly.
    The HCAHPS survey is currently available in English and Spanish. 
During the HCAHPS dry run and initial national implementation 
(discussed more fully below), we are soliciting comments from 
participating hospitals and survey vendors regarding additional 
languages for HCAHPS. This information can be submitted to our HCAHPS 
mailbox, [email protected]. From the information we receive, 
we will establish priorities for HCAHPS translation into additional 
languages.
    In order for the remaining hospitals to participate in HCAHPS, 
future training sessions for hospital personnel and survey vendors will 
take place in January 2007. Hospitals may choose to self-administer 
HCAHPS, or may choose to hire a vendor who has completed the training. 
A brief dry run of March 2007 discharges will allow newly participating 
hospitals and vendors to get ``first-hand'' experience with all phases 
of the data collection and submission process. Details about the HCAHPS 
requirements, and the additional requirements proposed for HCAHPS under 
the IPPS RHQDAPU program, are included in section XXII.C. and XXII.D. 
of this preamble.
    Comment: Commenters expressed appreciation for the iterative 
process that CMS engaged in with the hospital field and other Federal 
agencies such as AHRQ in the development and then implementation of 
HCAHPS.
    Response: We appreciate the comments and the input we received from 
stakeholders during the development process.
    Comment: Because HCAHPS is a new measure set for hospital data 
collection, one commenter opposed using HCAHPS as part of the IPPS 
RHQDAPU program

[[Page 68204]]

until at least 12 months of data have been abstracted, submitted, and 
validated.
    Response: For FY 2008, the IPPS annual payment update under the 
program is tied to reporting, not performance. This gives hospitals the 
opportunity to use HCAHPS without tying their scores to performance.
    HCAHPS has been rigorously tested and validated in collaboration 
with a public-private partnership (HQA) on hospital quality reporting. 
In addition, the National Quality Forum endorsed HCAHPS in May 2005 
(see final report at http://www.qualityforum.org) and it has received 
final approval from the Federal OMB (December 2005).
    In order to submit HCAHPS data, each hospital, either self-
administering or through use of a vendor, must participate in at least 
a one month dry run. The dry run mirrors all aspects of the data 
collection process: Sampling, survey administration, and data 
submission. The dry run allows participating providers to submit data 
without having it publicly reported. Hospitals that did not participate 
in the Spring 2006 dry runs will be required to carry out a dry run in 
March 2007 following training. Approximately 2,500 hospitals 
participated in the Spring 2006 dry run. These hospitals will have used 
HCAHPS for at least one year by July 2007.
    Unlike the clinical measures, hospitals cannot validate survey 
data. Therefore, our oversight focuses on ensuring vendors and 
hospitals are following the HCAHPS protocols. During this initial 
implementation prior to July 2007, CMS will begin conducting oversight 
activities to provide feedback to hospitals and survey vendors. We are 
also currently providing feedback based on the April, May and June 2006 
dry run submissions and will conduct a similar process for the March 
2007 dry run.
    After careful consideration of the public comments received, we are 
adopting as final the HCAHPS measure requirements we proposed.
3. Surgical Care Improvement Project (SCIP) Quality Measures
    The Surgical Care Improvement Project (SCIP) is a national quality 
partnership of organizations committed to improving the safety of 
surgical care through the reduction of post-operative complications. 
The primary goal of the partnership is to save lives by reducing the 
incidence of surgical complications by 25 percent by the year 2010.
    Partners in SCIP believe that a meaningful reduction in 
complications requires a systems approach to our challenges, which 
means that surgeons, anesthesiologists, primary care physicians and 
internal medicine specialists, perioperative nurses, pharmacists, 
infection control professionals, and hospital executives must work 
together to make surgical care improvement a priority. SCIP partners 
coordinate their efforts through a steering committee that includes 
representatives of the American Hospital Association, the American 
College of Surgeons, the American Society of Anesthesiologists, the 
Association of Perioperative Registered Nurses, the JCAHO, the 
Institute of Healthcare Improvement, the Department of Veterans Affairs 
(VA), the AHRQ, the Centers for Disease Control and Prevention (CDC) 
and CMS.
    SCIP is a comprehensive program, integrated into the quality 
improvement agenda of the CMS, JCAHO, the CDC, the American College of 
Surgeons, the VA's Veterans Health Administration, as well as the other 
organizations that comprise the SCIP Steering Committee. There are a 
number of activities underway from these and other partnering 
organizations. Hospital participation in the SCIP program is voluntary.
    We received a number of comments on the SCIP measures.
    Comment: One commenter applauded CMS' proposal to add SCIP-VTE 1 
and SCIP-VTE 2 to the IPPS RHQDAPU program. The commenter stated that 
adding these measures for hospitals reporting quality data under this 
program will help to improve quality of care for Medicare 
beneficiaries, and reduce the risk of post-operative complications 
associated with VTE.
    Response: We appreciate the comment as we recognize the importance 
of these measures in improving the quality of care provided to Medicare 
beneficiaries. We plan to continue to focus efforts on measures that 
will decrease the risk of surgical complications. We also look forward 
to the commenter's continued support as we expand the set of measures 
for the RHQDAPU program.
    Comment: One commenter expressed concern that the CMS Medicare 
Quality Improvement Community (MedQIC) has delineated inappropriate 
cost effectiveness factors for the SCIP target areas. MedQIC's SCIP 
target area of ``Deep vein thrombosis'' includes a discussion of the 
cost of low-dose unfractionated heparin (LDUH) versus the cost of low-
molecular-weight heparin (LMWH).
    Response: We have reviewed the information currently posted on 
MedQIC and the information pertaining to cost effectiveness factors for 
SCIP target areas is accurate. The statement from the SCIP Education 
Module (developed by the Florida QIO) about the cost of low-dose 
unfractionated heparin (LDUH) versus the cost of low-molecular weight 
heparin (LMWH) is not meant to be an endorsement of the lower cost 
thromboprophylaxis. As evident in the VTE prophylaxis recommendation 
table located in the Measure Information Form for SCIP-VTE-1 (found at 
http://www.QualityNet.com, select Hospitals, then Specifications Manual 
from the drop-down menu), both forms of thromboprophylaxis are listed, 
where appropriate.
    Comment: One commenter urged CMS to take the lead in developing a 
new VTE measure for prophylaxis of medical patients at risk for VTE. 
The commenter believed that this is consistent with NQF-endorsed safe 
practices. The commenter noted that the IPPS RHQDAPU program currently 
only includes measures for VTE prophylaxis in surgery patients and 
recommended that CMS expand the measure to include a measure for 
prophylactic treatment of medical patients at risk for VTE.
    Response: Currently, we are supportive of JCAHO's efforts to create 
VTE measures for the medical community and have provided technical 
support to that activity in conjunction with the alignment of other 
measures. We will continue to take an active part in making 
recommendations for additional measure development.
    Comment: One commenter commended CMS for the steps it has taken 
through the SCIP pilot to increase VTE prophylaxis in acute care 
hospitals. The commenter believed that the addition of the SCIP-VTE 1 
and 2 to the Hospital Compare Web site is an important step to 
improving prophylaxis and reducing complications in surgical patients. 
However, the commenter believed that there are a significant number of 
hospitalized nonsurgical patients who are at risk for VTE. The 
commenter stated VTE is a hospital-wide preventable condition; while 
addressing prophylaxis for surgical patients in the hospital setting is 
a necessary step, alone it is not sufficient to reduce the overall rate 
of VTE across the continuum of care.
    The commenter encouraged CMS to go beyond the silos of hospital 
setting and need based on surgery and address three critical areas:
     Continuity of prophylaxis into other treatment setting 
after surgery;
     Prophylaxis for the medical patients in the hospital who 
are high risk of VTE;

[[Page 68205]]

     Outcome measures for all hospitalized patients, at 90 days 
for re-hospitalization for symptomatic VTE and mortality.
    Response: We believe that the clinical situation for non-surgical 
patients is very different. The NQF has endorsed surgical VTE 
prophylaxis measures, but has not endorsed any VTE prophylaxis measures 
for the non-surgical patient. We are working closely with JCAHO in its 
work regarding VTE prophylaxis in the non-surgical patient. That work 
is very time consuming and final measures will take a significant 
amount of time to create and then test. In the interim CMS will move 
ahead with those measures for surgical patients.
    After careful consideration of the public comments received, we are 
adopting as final the SCIP requirements we proposed.
4. Mortality Outcome Measures
    CMS recognizes that the current set of hospital performance 
measures should be expanded to more fully reflect outcomes of care. The 
30-day mortality measures for patients with acute myocardial infarction 
(AMI), heart failure (HF) and pneumonia are three separate claims-
based, risk-adjusted assessments of mortality within 30 days of 
admission for each of the three conditions. The measures reflect 
outcomes of care for Medicare patients only, and rely on Medicare 
patients' historical medical care use, including inpatient and 
physician office visits and outpatient care 1 year before their 
hospitalizations, for the risk adjustment calculation.
    The 30-day mortality rate measures for AMI and HF were endorsed by 
the NQF in 2005 (see http://www.qualityforum.org/news/tb3Hospspecsforweb02-10-06.pdf). We anticipate that the 30-day 
mortality rate measure for pneumonia will also be endorsed by the NQF 
since it reflects the same underlying methodology as the other 30-day 
mortality measures.
    In contrast to the HCAHPS and SCIP quality measures added to the 
measure set for FY 2008, no additional data collection from hospitals 
will be required to calculate the 30-day mortality measures. All three 
measures can be calculated based on Medicare inpatient and outpatient 
claims data that are already reported to the Medicare program for 
payment purposes. We anticipate that we will conduct a national dry run 
for the AMI and HF measures in late 2006 to test implementation and 
educate hospitals on the methodology. During this dry run, hospitals 
will be given the opportunity to examine their rates and other data 
associated with the measures, and to provide feedback to CMS on 
questions related to the calculation of the rates. The rates that will 
be developed for the dry run will be used for quality improvement 
purposes and will not be publicly reported to the Hospital Compare. 
More information about the dry run will be provided to hospitals 
through the QualityNet Exchange Web site (http://www.qnetexchange.org).
    We proposed to calculate and publicly report 30-day mortality rates 
for the AMI and HF conditions in the June 2007 update of the Hospital 
Compare Web site. Under the proposal, rates for the 30-day pneumonia 
mortality measure would be posted as soon as possible after we receive 
NQF endorsement. As is currently the case for the other measures, 
hospitals would be provided a 30-day period in which they would be 
permitted to preview their rates before publication. As is currently 
the case for the ``starter set'' measures, hospitals that pledged to 
submit data for full annual payment update for FY 2008 would not be 
permitted to suppress or withhold publication of the rates on the 
Hospital Compare Web site, except under highly limited circumstances.
    Comment: Three commenters believed that use of the 30-day risk 
adjusted mortality measures for acute myocardial infarction and heart 
failure patients did not represent the best outcome measures that could 
be selected by Medicare to represent the quality of care delivered to 
patients in hospitals. The commenters recommended that CMS identify 
outcome measures that better reflect the quality of hospital care.
    Response: We are interested in identifying other outcome measures 
that reflect quality hospital care that are of importance to consumers. 
However, the 30-day risk adjusted mortality measures for acute 
myocardial infarction and heart failure complement the other AMI and HF 
measures already reported on Hospital Compare and will provide 
additional information to consumers regarding the quality of care for 
these two important conditions. The evidence underlying the process 
measures for the cardiac conditions is based on outcomes of care 
(usually mortality) measured at a specified time interval (most 
frequently 30 days). Also, length of stay varies by hospital due to 
local custom, efficiency and transfer policies. For these reasons we 
believe that 30 day risk-adjusted mortality is a better outcome measure 
to measure the quality of care delivered to patients in hospitals than 
in-patient mortality. In addition, these measures were unanimously 
recommended by the NQF Scientific Committee as the sole claims-based 
30-day mortality measures that met the NQF's stringent scientific 
criteria. The measures were subsequently NQF-endorsed through its 
consensus development process.
    Comment: One commenter believed that the use of the 30-day risk 
adjusted mortality for acute myocardial infarction is not congruent 
with the in-hospital mortality measures that are part of the JCAHO core 
measures for acute myocardial infarction and an outcome measure that is 
being used in the Premier Hospital Quality Incentive Demonstration 
project.
    Response: It is our understanding that the once CMS begins publicly 
reporting these 30-day mortality measures on Hospital Compare, JCAHO 
will no longer independently report inpatient mortality. The 30-day 
mortality measures include both patients who expire while in the 
hospital and patients who expire after discharge. We believe that the 
30-day measure is a better measure to assess hospital performance 
because a standardized period of time over which performance is 
assessed is particularly important because (1) length of stay varies by 
hospital due to local custom, efficiency and transfer policies, and (2) 
limiting reporting to in-hospital mortality would provide a strong 
incentive for hospitals to adopt strategies to transfer people who are 
dying to other facilities (other acute care hospitals or SNFs or home).
    Comment: One commenter recommended that CMS publicly recognize the 
limitations associated with the use of the mortality measures, as every 
risk-adjustment methodology has limitations based on its underlying 
assumptions that the data is available and used in those calculations. 
Additionally, the commenter recommended that CMS to be open to refining 
the risk adjustment methodology and/or selection of alternate outcome 
measures based on hospital and health system recommendations.
    Response: We will make the mortality measures methodology 
transparent to the public by posting the report on the risk adjustment 
methodology and measure specifications on the CMS website at http://www.cms.hhs.gov or http://www.cms.hhs.gov/HospitalQualityInits/. The 
limitations of the measures will be a part of the report. Furthermore, 
hospitals and health systems will have the opportunity to examine the 
methodology, review their own data, and provide feedback to CMS in a 
national ``dry run'' of the measures

[[Page 68206]]

prior to public reporting. We also plan to continue refining and 
updating the mortality measures in order to ensure the scientific 
soundness of the measure methodology.
    Comment: One commenter supported the use of outcome quality 
measures such as the 3 mortality measures. However, the commenter 
believed that CMS must make its risk adjustment method completely 
transparent to all stakeholders prior to using these measures of 
quality and noted that the propose rule does not contain a transparent 
explanation of how risk adjustments will be made.
    Response: We will make the risk adjustment methodologies and 
measure specifications available to the public. Furthermore, prior to 
publicly reporting these mortality measures on Hospital Compare, CMS 
will conduct a dry run with all the hospitals in the nation. CMS will 
not post the hospital mortality rates on the Hospital Compare Web site 
during the dry run. The dry run is intended to give hospitals an 
opportunity to have experience with the measures and the risk 
adjustment methodology and review their mortality rates prior to public 
reporting. Hospitals will also have an opportunity to send their 
feedback to CMS during the dry run.
    After careful consideration of the public comments received, we are 
therefore adopting as final the AMI and heart failure mortality measure 
requirements we proposed. When we proposed adding the pneumonia 
mortality measure for the FY 2008 IPPS RHQDAPU program, we believed 
that it would soon be endorsed by the NQF. However, the NQF has not yet 
endorsed the pneumonia mortality measure. Therefore, we are not 
adopting the pneumonia mortality measure in this final rule. We intend 
to adopt this measure after the NQF endorses it. At the time we 
determine to adopt the measure, we would finalize our proposal to adopt 
the pneumonia mortality measure in a notice published in the Federal 
Register.

C. General Procedures and Participation Requirements for the FY 2008 
IPPS RHQDAPU Program

    All revised procedures for FY 2008 also will be added to the 
``Reporting Hospital Quality Data for Annual Payment Update Reference 
Checklist'' section of the QualityNet Exchange Web site. This checklist 
also links to all of the forms to be completed by hospitals 
participating in the program.
    To participate in the RHQDAPU program, as we proposed, we are 
requiring that hospitals must follow these steps:
     Complete all registration steps; this information can be 
found on ``Reporting Hospital Quality Data for Annual Payment Update 
Reference Checklist'' located on the QualityNet Exchange Web site.
     Continue to collect data for all clinical quality measures 
that are currently part of the RHQDAPU program, and submit the data to 
the QIO Clinical Warehouse either using the CMS Abstraction & Reporting 
Tool (CART), the JCAHO ORYX[reg] Core Measures Performance Measurement 
System, or another third-party vendor tool that has met specification 
requirements for data transmission to QualityNet Exchange. For HCAHPS, 
the submission needs to be in the required XML formats or through the 
online data submission tool. The submission must be done through 
QualityNet Exchange. Because the information in the QIO Clinical 
Warehouse is considered QIO information, it is subject to the stringent 
QIO confidentiality regulations in 42 CFR Part 480.
    In addition, for purposes of the annual payment update, we will 
continue to require hospitals to pass our validation requirements for 
the clinical quality measures. We originally set forth these 
requirements in the FY 2006 IPPS final rule (70 FR 47421), and we will 
continue to require that hospitals achieve an 80-percent reliability. 
We will also continue to post information related to validation 
requirements on the QualityNet Exchange Web site.
    In addition to these general procedures, the specific procedures 
below apply to these additional measures.

D. HCAHPS Procedures and Participation Requirements for the FY 2008 
IPPS RHQDAPU Program

1. Introduction
    Under sections 1886(b)(3)(viii)(III) and 1886(b)(3)(B)(viii)(IV) of 
the Act, CMS must begin to adopt the baseline set of performance 
measurements as set forth in a 2005 report issued by the Institute of 
Medicine (IOM) of the National Academy of Sciences under section 238(b) 
of Public Law 108-173, effective for payments beginning with FY 2007. 
CMS is expanding the set of IOM measures that hospitals will be 
required to report to receive the full IPPS market basket update for FY 
2008. In accordance with the recommendation of the 2005 IOM report, CMS 
is expanding the ``starter'' measures by including the HCAHPS patient 
perspective survey. In accordance with section 1886(b)(3)(B)(viii)(V) 
of the Act, CMS is also adding ``other measures that reflect consensus 
among affected parties and, to the extent feasible and practicable,'' 
and include ``measures set forth by one or more national consensus 
building entities.'' Accordingly, CMS will add additional SCIP quality 
measures and two 30-day mortality measures, as discussed in section 
XXII.E. of this preamble.
2. HCAHPS Hospital Pledge and Beginning Date for Data Collection
    We proposed that hospitals will need to submit HCAHPS data to the 
QIO Clinical Warehouse beginning with discharges that occur in the 
third calendar quarter of 2007 (July through September discharges) in 
order to be eligible for the full FY 2008 IPPS market basket update. In 
order to meet HCAHPS requirements for the RHQDAPU program, we proposed 
that all hospitals, including hospitals new to HCAHPS and hospitals 
that have been collecting data since October 1, 2006, must submit a 
formal pledge to CMS by July 1, 2007 stating that they will collect and 
submit HCAHPS data to the QIO Clinical Warehouse starting with July 
2007 discharges. We proposed that to meet HCAHPS requirements for the 
RHQDAPU program for FY 2008, all hospitals must submit this pledge to 
CMS.
    Comment: One commenter wanted clarification as to whether all 
hospitals need to submit the pledge or just hospitals eligible for the 
RHQDAPU program.
    Response: The pledge form referenced in the rule is for 
participation in the RHQDAPU program, so only hospitals eligible for 
the RHQDAPU program need to submit it.
    Comment: One commenter recommended that CMS include HCAHPS in the 
annual formal pledge form for participation in the RHQDAPU program.
    Response: We agree that it will be less confusing to hospitals to 
have one pledge form for both the clinical measures and HCAHPS. We will 
be combining all of the measures, including HCAHPS, into the RHQDAPU 
Notice of Participation form that hospitals fill out and submit to 
their QIO each summer.
    Comment: One commenter requested that the RHQDAPU participation 
form be made available to submit electronically.
    Response: The RHQDAPU Notice of Participation form is available 
electronically on http://www.qualitynet.org. Submitters must mail or 
fax their signed forms to the

[[Page 68207]]

QIOs. The QIOs then enter the information into the Program Resource 
System (PRS).
    We are finalizing our proposal to require that, in order to be 
eligible for the full FY 2008 IPPS market basket update, hospitals must 
submit a pledge stating that they will collect and submit HCAHPS data 
to the QIO Clinical Warehouse starting with July 2007 discharges. This 
pledge will be part of the RHQDAPU Notice of Participation form for FY 
2008 that will include the clinical measures, HCAHPS, and the mortality 
measures. We will announce the deadline for the RHQDAPU Notice of 
Participation form at a future date.
3. HCAHPS Dry Run
    We are finalizing our proposal to require hospitals that have not 
had experience collecting and submitting HCAHPS data to the QIO 
Clinical Warehouse as a result of participating in the 2006 voluntary 
initiative must participate in a dry run of the survey in March 2007. 
We proposed to require the submission of March 2007 dry run data to the 
QIO Clinical Warehouse by July 13, 2007 from those hospitals not yet 
collecting and submitting HCAHPS data. We received no comments on this 
proposal.
4. HCAHPS Data Collection Requirements
    We also are finalizing our proposal that, to collect HCAHPS data, a 
hospital can either contract with an approved HCAHPS survey vendor that 
will conduct the survey and submit data on the hospital's behalf to the 
QIO Clinical Warehouse, or a hospital can self-administer the survey 
without using a survey vendor provided that the hospital meets Minimum 
Survey Requirements as specified at (http://www.HCAHPSonline.org/programapplication.asp). A current list of approved HCAHPS survey 
vendors can be found at http://www.HCAHPSonline.org/app_vendor.asp. We 
received no comments on this proposal.
5. HCAHPS Registration Requirements
    We are adopting as final our proposal that HCAHPS registration 
requirements for the IPPS RHQDAPU program will include the following:
    The hospital must be a registered user of QualityNet Exchange. 
Hospitals that are self-administering HCAHPS or survey vendors hired by 
the hospitals must collect and submit HCAHPS survey person-level data 
electronically to the QIO Clinical Warehouse via QualityNet Exchange, 
using prescribed file specifications that can be found at http://www.HCAHPSonline.org/techspecs.asp. We received no comments on this 
proposal.
6. Additional Steps for HCAHPS Participation
    We are finalizing our proposal that, in order to participate in 
HCAHPS, hospitals that self-administer the survey and survey vendors 
that collect and submit data on behalf of client hospitals must follow 
these steps:
     Attend Hospital/Survey Vendor Training. Hospitals and 
survey vendors that intend to actually administer the survey must 
attend HCAHPS training. Hospitals contracting with a survey vendor or 
another hospital to administer the survey on behalf of the hospital do 
not need to attend training. The next training session will be offered 
via Webinar in late January 2007. Please see http://www.HCAHPSonline.org for updated information on training opportunities 
and registration. At a minimum, the hospital's or survey vendor's 
project manager must attend the HCAHPS training for administering the 
survey. Hospitals and survey vendors that attended training in February 
or April 2006 and are participating in the voluntary HCAHPS data 
submission beginning October 2006 do not need to participate in the 
January 2007 training sessions. In addition, we may hold short 
refresher training sessions for all hospitals self-administering the 
survey and survey vendors in the spring of 2007.
     Review and follow the HCAHPS Quality Assurance Guidelines 
and Updates. HCAHPS Quality Assurance Guidelines have been developed to 
standardize the survey data collection process and to ensure 
comparability of data reported through HCAHPS. They are located on 
http://www.HCAHPSonline.org and will also be presented at the HCAHPS 
hospital/survey vendor training.
    The HCAHPS Quality Assurance Guidelines (the Guidelines) provide 
detailed information regarding: technical support; sampling protocols; 
the four allowed modes of survey administration; data specifications 
and coding; data preparation and submission; data reporting and the 
exceptions process. The Guidelines describe technical support that is 
available to hospitals and survey vendors administering HCAHPS by using 
a toll-free number or by e-mail. The Guidelines provide details 
regarding the protocol for sampling, which is based on drawing a simple 
random sample each month from the sampling frame of eligible 
discharges. Sampling can be done at one time after the end of the 
month, or continuously throughout the month, as long as a simple random 
sample is generated for the month. The Guidelines include very specific 
information about the four allowed modes of survey administration: mail 
only, telephone only, a mixed methodology of mail with telephone follow 
up, and active interactive voice response (IVR). All modes of 
administration require following a standardized protocol. The 
Guidelines describe a standardized approach for handling all data, 
including assigning the unique tracking number, the decision rules for 
capturing data, the file specifications, the file layout, the procedure 
for assigning disposition codes, the definition of a completed survey, 
and the procedure for calculating the total survey response rate. Data 
preparation and submission guidelines cover registration for data 
submission via the QualityNet Exchange, creation of data files, 
instructions for data submission via the QualityNet Exchange, and 
confirmation of accuracy of data. Data reporting covers internal and 
external reports; among them are the hospital preview reports and the 
public reports on CMS Hospital Compare. The Quality Assurance 
Guidelines describe the exceptions process to review requests for 
methodologies that vary from the standard HCAHPS protocols, and the 
appeals process if an exception is denied. For the initial 
implementation phase of the HCAHPS survey, no exceptions to the four 
approved modes of survey administration will be allowed.
    In addition, hospitals/survey vendors must follow any updates that 
are posted on http://www.HCAHPSonline.org.
     Develop Hospital/Survey Vendor HCAHPS Quality Assurance 
Plan. Hospitals self-administering the survey and survey vendors must 
develop a Quality Assurance Plan for survey administration in 
accordance with the Quality Assurance Guidelines presented at the 
HCAHPS hospital/survey vendor training and posted on http://www.HCAHPSonline.org/programapplication.asp. The HCAHPS Quality 
Assurance Plan should include the following:
    + Organizational chart
    + Work plan for survey implementation
    + Description of survey procedures and quality controls
    + Plans for quality assurance oversight of on-site work and of all 
subcontractors' work
    + Confidentiality/Privacy and Security procedures in accordance 
with

[[Page 68208]]

the Health Insurance Portability and Accountability Act (HIPAA).
    The hospital or survey vendor must make the HCAHPS Quality 
Assurance Plan available to the HCAHPS project team upon request. The 
project team includes CMS, the Health Services Advisory Group (HSAG) 
that is helping CMS implement HCAHPS, and HSAG's subcontractors for 
this project.
     Attest to the Accuracy of the Organization's Data 
Collection. Hospitals self-administering the survey and survey vendors 
must review and agree that the HCAHPS survey was administered in 
accordance with the HCAHPS Quality Assurance Guidelines.
     Participate in HCAHPS oversight activities. Hospitals and 
survey vendors must participate in a quality oversight process 
conducted by the HCAHPS project team. Prior to July 2007, the purpose 
of the oversight activities will be to provide feedback to hospitals 
and survey vendors on data collection procedures. Starting in July 
2007, CMS may ask hospitals/survey vendors to correct any problems that 
are found and provide follow-up documentation of corrections for review 
within a defined time period. If we find that the hospital has not made 
these corrections, CMS may determine that the hospital is not 
submitting appropriate HCAHPS data for the RHQDAPU program.
    As part of these activities, HCAHPS project staff will review and 
discuss with survey vendors and hospitals self-administering the survey 
their specific Quality Assurance Plans, survey management procedures, 
sampling and data collection protocols, and data preparation and 
submission. This review may take place in-person or through other means 
of communication.
    Comment: One commenter asked how the integrity of HCAHPS survey 
will be protected if it is sent to a prisoner or mentally incapacitated 
patient. The commenter also asked how CMS will validate that the survey 
was actually completed by the patient.
    Response: Hospitals participating in the HCAHPS survey are 
instructed to exclude certain categories of patients from the universe 
of patients to whom the survey may be administered. These excluded 
categories encompass, among others, both prisoners and patients 
admitted to hospital for psychiatric treatment. In addition, 
psychiatric hospitals, as defined under section 1861(f) of the Act, do 
not participate in the RHQDAPU program because they are excluded from 
the IPPS.
    To ensure that the patient completes the survey, hospitals 
participating in HCAHPS and the survey vendors that administer the 
survey on their behalf must notify all patients they survey that only 
the patient himself or herself should complete the survey. Survey 
vendors conducting telephone surveys may only speak directly to the 
patient. If they reach a family member or someone other than the 
patient, that person cannot complete the survey. There are instructions 
on all mail surveys that only the patient may complete the survey.
    Comment: Some commenters expressed concern about having yet another 
entity that hospitals and health systems need to be familiar with, 
especially since they deal primarily with the QIO regarding issues 
around quality measurement, submission of data to the QIO Clinical 
Warehouse, annual payment update, and appeals related to chart 
validation. These commenters asked whether the QIOs have any 
involvement with HCAHPS.
    Response: The submission of HCAHPS data is similar to the data 
submission for the clinical measures. We have contracted with the Iowa 
Foundation of Medical Care (IFMC) for the data submission through 
QualityNet Exchange and the QIO Clinical Warehouse, and with the Health 
Services Advisory Group, Inc. (HSAG) of Arizona for all technical 
assistance and support for HCAHPS. HSAG is fully available to 
accommodate assistance needs on a national basis for HCAHPS. We believe 
that this carefully coordinated effort will ensure a high level of 
reliability of data collection, data submission and data oversight 
since consistency of protocols is essential to the success of this 
survey and to assuring quality data reporting to the public. In 
addition to these two QIOs (IFMC and HSAG), we anticipate that all QIOs 
will be involved in the preview process prior to public reporting.
7. HCAHPS Survey Completion Requirements
    We also are finalizing our proposal to require hospitals to submit 
complete HCAHPS data in accordance with the HCAHPS Quality Assurance 
Guidelines located at http://www.HCAHPSonline.org and made available at 
the hospital/survey vendor training. These requirements specify that 
hospitals are required to survey a random sample of eligible discharges 
on a monthly basis. Hospitals should target to collect at least 300 
completed surveys over the public reporting period. For the initial 
HCAHPS national implementation, the public reporting period is 9 months 
(October 2006 through June 2007) due to broad interest in making HCAHPS 
results publicly available as quickly as possible. As discussed above, 
participation in this initial 9 month reporting period is not a 
requirement under the RHQDAPU program and hospitals do not need to 
participate in this initial reporting period in order to receive the 
full FY 2008 IPPS market basket update. After this initial 
implementation, reporting of HCAHPS data will be required under the 
RHQDAPU program. The public reporting period will be 12 months and 
hospitals should be targeting to collect at least 300 completed HCAHPS 
surveys over a 12 month period. Smaller hospitals that cannot collect 
300 completed HCAHPS surveys during a public reporting period will only 
be required to collect as many completed surveys as possible. A small 
hospital is defined for the purposes of HCAHPS as any hospital that 
cannot achieve 300 completed HCAHPS surveys during a public reporting 
period because of its dearth of eligible hospital discharges during 
that period. For hospitals that cannot collect 300 completed HCAHPS 
surveys, we plan to note on http://www.hospitalcompare.hhs.gov that the 
results for these hospitals are based on less than 100 completed HCAHPS 
surveys, or between 100 and 299 completed HCAHPS surveys.
8. HCAHPS Public Reporting
    We are finalizing our proposal to display HCAHPS data on our Web 
site for public viewing in accordance with section 
1886(b)(3)(B)(viii)(VII) of the Act, which states that the Secretary 
must report quality measures that relate to patients' perspectives of 
care on our Web site. Before we display this information, hospitals 
will be permitted to review their data to be made public as we have 
recorded it.
    As discussed above, there are 27 questions included in the HCAHPS 
survey. The survey is comprised of substantive questions that directly 
pertain to seven domains of primary importance to the target audience: 
doctor communication; nurse communication; cleanliness and quiet of the 
hospital environment; responsiveness of hospital staff; pain 
management; communication about medicines; and discharge information. 
The survey also includes two overall questions that measure the 
patient's overall satisfaction with the hospital and willingness to 
recommend the hospital.
    Each of the seven domains is constructed from two or three 
questions from the survey and is reported as a composite score. For 
public reporting purposes, the seven composite scores or items from 
within these domains and

[[Page 68209]]

two overall ratings will be displayed. There will be both national and 
state comparisons for each of the reported results. We are currently 
conducting testing with consumers to ensure that the HCAHPS displays on 
http://www.hospitalcompare.hhs.gov are consumer friendly. Generally, 
for CAHPS[reg] measures in other settings we display bar graphs with 
the top response categories, such as the percent of people surveyed 
that gave the hospital a ``10'' for a 0 to 10 rating, or the percent 
that said their doctors ``always'' communicate well. Users of the site 
can ``drill down'' to get more detailed information regarding the 
distribution for the response categories underlying the survey 
questions.
    Comment: A commenter noted that the proposed rule does not contain 
a transparent explanation of how risk adjustments will be made.
    Response: We will adjust HCAHPS data for mode and patient-mix 
effects prior to public reporting. We will adjust hospital results to 
``level the playing field'' by adjusting for factors not directly 
related to hospital performance: mode of survey administration, 
patient-mix, and non-response tendencies. An HCAHPS Mode Experiment was 
conducted for several months in 2006, and the data analyses are now 
underway. The adjustment algorithm will be made available prior to the 
public reporting of HCAHPS results. The mode experiment results, 
including the adjustments to be made, will be available in late 2006 on 
http://www.HCAHPSonline.org. Several questions on the HCAHPS survey, as 
well as some items from hospital administrative data, will be used for 
patient mix adjustment.
    Comment: A commenter supported publicly reporting HCAHPS survey 
data in seven composites and two overall ratings displayed on the 
Hospital Compare Web site. However, the commenter suggested that CMS 
consider retaining the ability for consumers to drill down so that they 
may assess the hospital's performance related to a single question.
    Response: We appreciate this sensitivity to consumers' need to 
assess specific information. We are currently testing and assessing 
various data displays for use on the Hospital Compare Web site. We will 
be testing drill-downs with consumers and after the testing is 
completed will determine the best way to display HCAHPS data. We are 
also testing the seven composites to ensure that they work well for the 
displays and are consumer friendly.
    Comment: A commenter asked CMS to continue to allow private sector 
organizations to have full access to provider performance information 
from the CMS Compare Web site and that the performance information for 
each question (rather than just the composite scores) on the HCAHPS 
survey be available for download.
    Response: We are considering different options for the downloadable 
database and will take this request into consideration as this database 
is developed.
9. Reporting HCAHPS Results for Multi-Campus Hospitals
    Currently, hospitals that share Medicare provider numbers combine 
their clinical data across campuses for submission and publication of 
their data. We proposed to combine HCAHPS data across campuses. 
However, we are considering ways in which data could potentially be 
displayed by campus rather than by hospital system in the future. As a 
starting point, we are trying to determine a way to identify those 
hospitals that share Medicare provider numbers, which will allow CMS to 
denote that the measures are made up of multiple campuses on http://www.hospitalcompare.hhs.gov. In the future, if feasible, we would like 
to move towards obtaining and reporting information at the campus 
level. In the CY 2007 OPPPS proposed rule, we encouraged comments 
regarding this issue.
    Comment: One commenter recommended that all hospital data be 
treated consistently by reporting both clinical quality and HCAHPS data 
by Medicare provider number or by individual hospital.
    Response: We agree that data should be reported consistently for 
both clinical quality and HCAHPS data, either by Medicare provider 
number or by individual hospital.
    Comment: A commenter applauded CMS' interest in determining a way 
to identify those hospitals that share a Medicare provider number and 
move toward displaying performance information by campus rather than by 
hospital system as it provides consumers with more information to 
assist in decisions about where to obtain services.
    Response: We appreciate the comment and will continue to explore 
ways to obtain and report information at the campus level.
    Currently, hospitals that share Medicare provider numbers combine 
their clinical data across campuses for submission and publication of 
their data. For purposes of the FY 2008 RHQDAPU program, we are 
adopting our proposal to require hospitals to combine their HCAHPS data 
for all campuses of a multi-campus provider. For each reporting period, 
which is 12 months starting in July 2007, hospitals that share a 
Medicare provider number need to obtain 300 survey completes across 
their multiple campuses. CMS will continue to explore ways to collect 
and report the data by campus in the future.

E. SCIP & Mortality Measure Requirements for the FY 2008 RHQDAPU 
Program

     We proposed that hospitals be required to complete and 
return a written form on which they agree to participate in the RHQDAPU 
program for FY 2008.
     For the SCIP measures, we proposed to require hospitals to 
submit data starting with discharges that occur in CY 2007. Hospitals 
will be required to submit data on these measures to the QIO Clinical 
Warehouse beginning with discharges that occur in the first calendar 
year quarter of 2007 (January through March discharges). We proposed 
that the deadline for hospitals to submit their data for first calendar 
quarter of 2007 will be August 15, 2007.
     For the Mortality measures, we proposed to use claims data 
that is already being collected for index hospitalizations to calculate 
the mortality rates. Therefore, no additional data will need to be 
submitted by hospitals for these measures. Index hospitalization is the 
initial hospitalization for an episode of care. Claims data submitted 
to CMS for index hospitalizations occurring from July 2005 through June 
2006 (3rd quarter CY 2005 through 2nd quarter CY 2006) will be used to 
calculate the mortality rates that will be used for FY 2008 annual 
payment determination. These rates will be posted on Hospital Compare 
in June 2007.
     We proposed to display on our Web site data collected on 
the SCIP and Mortality measures for public viewing in accordance with 
section 1886(b)(3)(B)(viii)(VII) of the Act. Before we display this 
information, hospitals will be permitted to review their data that are 
to be made public as we have recorded it.
    Comment: One commenter stated that, for the SCIP-VTE 1, SCIP-VTE 2, 
and SCIP Infection 2 measures, the proposed time frame to report these 
measures do not allow for hospitals to have sufficient staff on board 
and to make sure they are properly educated and trained to ensure a 
high degree of accuracy in the data abstraction. The commenter 
recommends that CMS require hospitals submit data for these measures

[[Page 68210]]

beginning with discharges in the third quarter 2007 (July through 
September 2007).
    Response: Collection of SCIP-Infection 1 and SCIP-Infection 3 as 
RHQDAPU measures for FY 2008 (which we adopted for purposes of the 
RHQDAPU program in the FY 2007 IPPS final rule) began third calendar 
quarter of 2006. The data submission deadline for third calendar 
quarter of 2006 is February 15, 2007. For those hospitals that are 
already collecting and submitting data for SCIP-Inf-1 and SCIP-Inf-3, 
the addition of SCIP-Inf-2 would require collection of only two 
additional data elements (questions). These two additional data 
elements include Antibiotic Allergy and Vancomycin. We believe the 
addition of these measures to the RHQDAPU measures beginning first 
quarter 2007 is a reasonable expectation for hospitals.
    Collection of the SCIP-VTE 1 and SCIP-VTE 2 measures began as a 
voluntary submission in fourth calendar quarter of 2006 (October 
through December discharges) under the Surgical Care Improvement 
Project (SCIP) discussed in section XXII.B.3. of this final rule with 
comment period. These measures were first published in the 
Specifications Manual for National Hospital Quality Measures in the 
October 2006 release of the manual, which was available June 9, 2006. 
This provided hospitals with an opportunity to abstract and submit 
these measures three months before the first calendar quarter of 2007, 
when they become RHQDAPU measures for FY2008.
    SCIP-VTE-1, SCIP-VTE-2, and SCIP-Inf-2 measures can be found in the 
Specifications Manual for National Hospital Quality Measures that was 
released in June 2006. This version of the manual pertains to fourth 
calendar quarter of 2006 and forward (October through December 
discharges).
    Comment: One commenter noted that, for the SCIP-VTE 1, SCIP-VTE 2, 
and SCIP Infection 2 measures, hospitals and health systems require 
time to work with their respective performance vendors to make sure 
that all tools are available to allow them to do the chart abstraction.
    Response: The above SCIP-Inf-2 has been collected since first 
calendar quarter of 2005 as part of the HQA. The Specifications Manual 
for National Hospital Quality Measures for fourth quarter 2006 
discharges has been available to Vendors since June 9, 2006. SCIP-VTE 1 
and SCIP-VTE 2 have been collected since fourth quarter 2006 under 
SCIP. Based on their inclusion in the SCIP or HQA efforts, these 
measures have been incorporated in the August and October releases of 
the CART and ORYX[supreg] tools so there should be no concern regarding 
the availability of data collection tools. Hospitals may use these 
tools immediately.
    As discussed above, after careful consideration of the public 
comments received, we are adopting as final the SCIP requirements we 
proposed.

F. Conclusion

    We believe that our decision to include HCAHPS, SCIP and mortality 
measures as part of the FY 2008 IPPS RHQDAPU program's reporting 
requirements meets the requirements of section 1886(b)(3)(B)(viii)(III) 
of the Act. This provision states that we must expand for FY 2007 and 
each subsequent fiscal year, consistent with sections 
1886(b)(3)(B)(viii)(IV) through 1886(b)(3)(viii)(VII) of the Act, the 
set of measures that the Secretary determines to be ``appropriate'' for 
the measurement of care furnished by hospitals in inpatient settings 
beyond the original 10-measure starter set of quality measures that 
applied in FY 2005 and FY 2006.
    Section 1886(b)(3)(B)(viii)(IV) of the Act requires us to begin to 
adopt the baseline set of performance measures set forth in the 2005 
IOM report effective for payment beginning with FY 2007. We began to 
adopt these measures for FY 2007 and are now adopting additional 
measures, including several measures from this report. HCAHPS and the 
SCIP Infection 2 measures are measures set forth in the 2005 IOM 
report. Thus, we believe our decision to expand the measure set to 
include HCAHPS and SCIP Infection 2 measures for the FY 2008 IPPS 
RHQDAPU program meets this requirement of the Act.
    Section 1886(b)(3)(B)(viii)(V) of the Act states that effective for 
payments beginning with fiscal year 2008, we must add ``other measures 
that reflect consensus among affected parties and, to the extent 
feasible and practicable,'' and include ``measures set forth by one or 
more national consensus building entities.'' In addition to adding 
additional measures from the baseline measures found in the 2005 IOM 
report, we are adding additional SCIP quality measures and two 30-day 
mortality measures. In selecting these measures to adopt consistent 
with this section for the FY 2008 payment update and thereafter, CMS is 
adding standardized quality measures that have been adopted or endorsed 
by a national consensus building entity that utilizes a national 
consensus building process that endorses measures based on: (1) Its 
consideration of issues such as the validity, reliability, impact and 
feasibility of the measures; and (2) input from a wide variety of 
stakeholders including, but not limited to, health care consumers and 
patients, clinicians and providers, purchasers, and researchers.
    We believe that adopting measures that have been endorsed as a 
result of this process achieves the type of consensus that Congress 
envisioned in enacting section 5001(a) of Public Law 109-171. The NQF 
is one consensus building entity that administers this process and 
takes these factors into account when endorsing measures. NQF is a 
voluntary consensus standard-setting organization established to 
standardize health care quality measurement and reporting, for its 
review and endorsement through its consensus development process. NQF 
endorsement, which occurs following a thorough, multi-stage review 
process, represents the consensus of numerous health care providers, 
consumer groups, professional associations, purchasers, Federal 
agencies, and research and quality organizations. We recognize that the 
30-day Pneumonia mortality is not currently NQF-endorsed. Therefore, as 
discussed above, we have decided not to adopt the 30-day Pneumonia 
mortality measure in this final rule with comment period.
    The HQA is another such consensus building entity. The HQA is a 
public-private collaboration of numerous stakeholder groups. One goal 
of HQA is to identify a robust set of standardized and easy-to-
understand hospital quality measures that would be used by all 
stakeholders in the health care system in order to improve quality of 
care and the ability of consumers to make informed health care choices. 
We also note that HQA currently relies on the NQF process as part of 
its process.
    CMS anticipates that other consensus building entities that take 
into account the issues of validity, reliability, impact and 
feasibility of the measures and involves a wide array of stakeholders 
may develop.

XXIII. Files Available to the Public Via the Internet

    Addenda A and B to this final rule with comment period provide 
various data pertaining to the CY 2007 payments for services under the 
OPPS. Addendum AA to this final rule with comment period include 
various data pertaining to the ASC list of covered procedures and 
payment rates for procedures furnished in ASCs in CY 2007.
    To conserve resources and to make Addendum B more relevant to the 
OPPS, we are including in Addendum

[[Page 68211]]

B of this final rule with comment period HCPCS codes (including CPT 
codes) for services that are assigned a payable status indicator under 
the OPPS and HCPCS codes for which we are making a change in status 
indicator and/or APC assignment for CY 2007. A list of all active HCPCS 
codes and those codes discontinued as of December 31, 2006, regardless 
of their assigned payment status or comment indicators under the OPPS, 
is available to the public by clicking ``Addendum A and Addendum B 
Updates'' on the CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/.
    For the convenience of the public, we are also including on the CMS 
Web site a table that displays the HCPCS data in Addendum B sorted by 
APC assignment, identified as Addendum C. To access Addendum C and 
other supporting data files related to the CY 2007 update of the OPPS, 
go to http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage, and select regulation number ``CMS-1506-FC''. At 
this same Web site is a link to all of the FY 2007 IPPS wage index 
related tables from the FY 2007 IPPS final notice (71 FR 59886 through 
60043), as they would be used for the CY 2007 OPPS. Similarly, we are 
including Addendum AA on the CMS Web site at: http://www.cms.hhs.gov/center/asc.asp.
    For additional assistance, contact Chuck Braver, (410) 786-6719.

XXIV. Collection of Information Requirements

    Under the Paperwork Reduction Act (PRA) of 1995, we are required to 
provide 30-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the PRA requires that we 
solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    The following information collection requirements are included in 
this final rule with comment period and their associated burdens are 
subject to the PRA.

Additional Quality Measures for FY 2008: Surgical Care Improvement 
Project (SCIP)

    Section 5001(a) of the Deficit Reduction Act (DRA) of 2005 (Pub. L. 
109-171) sets out new requirements for the IPPS Reporting Hospital 
Quality Data for Annual Payment Update (RHQDAPU) program. Under section 
1886(b)(3)(B)(viii)(V) of the Act, for payments beginning with FY 2008, 
we are required to add other measures that reflect consensus among 
affected parties and, to the extent feasible and practicable, must 
include measures set forth by one or more national consensus building 
entities. In this final rule with comment period, we are setting out 
the additional measures that we require for FY 2008.
    The burden associated with this section is the time and effort 
associated with collecting, copying, and submitting the data. As part 
of the SCIP, we estimate that there will be approximately 3,700 
respondents per year. All of these hospitals already were required to 
submit SCIP Infection 1 and 3 to be eligible to receive the full IPPS 
market basket update for FY 2007. Additional surgical procedures 
covering approximately 6,000,000 discharges annually will be sampled at 
a 10-percent rate per hospital; therefore, an additional 600,000 
discharges will be abstracted and submitted by hospitals for the 
additional SCIP measures (SCIP Infection 2 and VTE 1, 2). The 10-
percent sampling rate is a minimum threshold specified in the most 
current version of the joint CMS/JCAHO Hospital Quality Measures 
Specifications Manual. We estimate that it will take 450,000 hours (3/4 
hour per sampled discharge) to abstract and submit data for these 
additional sampled discharges.
    In addition, hospitals must abstract and submit additional 
information needed for the additional SCIP measures covering the 
surgical procedures already covered in SCIP Infection 1 and 3. We 
estimate that about 275,000 discharges will be sampled and abstracted 
covering these surgical procedures. We estimate that it will take an 
additional 137,500 hours (1/2 hour per sampled discharge) for hospitals 
to abstract and submit this additional information. Both estimates 
include overhead.
    In total, we estimate that an additional 587,500 hours will be used 
by hospitals to abstract and submit the additional SCIP measures. This 
estimate includes overhead.
    Further, we note that there is no additional burden associated with 
the incorporation of mortality outcome measures as this information is 
currently collected with claims data.
    We have submitted a copy of this final rule with comment period to 
the OMB for its review of the aforementioned information collection 
requirements.
    This final rule with comment period also includes associated 
information collections for which CMS has obtained the OMB's approval. 
The following is a discussion of these currently OMB approved 
collections.
    As discussed in section XXII. of this preamble, the IPPS RHQDAPU 
program expands upon the Hospital Quality Initiative, which is intended 
to empower consumers with quality of care information to make more 
informed decisions about their health care while also encouraging 
hospitals and clinicians to improve the quality of care. The 
information collection associated with the IPPS RHQDAPU is the Hospital 
Quality Alliance (formerly known as the National Voluntary Hospital 
Reporting Initiative) --Hospital Quality Measures. The OMB approved 
this information collection under OMB control number 0938-0918, with an 
expiration date of December 31, 2008. As a result of the increase from 
10 to 21 quality measures, CMS created a revised information collection 
request to include the new quality measures. CMS announced the revised 
information collection in a 60-day Federal Register notice that 
published on June 9, 2006 (71 FR 33458). CMS will publish a 30-day 
Federal Register notice prior to the submission of the revised 
information collection outlined in this final rule with comment period 
to OMB.
    Further, as discussed in section XXII. of this preamble, for FY 
2008, we are expanding the IPPS RHQDAPU program to include the HCAHPS 
Survey, also known as the Hospital CAHPS or the CAHPS Hospital Survey. 
The HCAHPS Survey is composed of 27 questions: 18 substantive questions 
that encompass critical aspects of the hospital experience 
(communication with doctors, communication with nurses, responsiveness 
of hospital staff, cleanliness and quietness of hospital environment, 
pain management, communication about medicines, and discharge 
information); 4 questions to skip patients to appropriate questions; 3 
questions to adjust for the mix of patients across hospitals; and 2 
questions to support congressionally mandated reports. As explained in 
section XXII. of this preamble, CMS published a Federal Register notice 
soliciting comments on the draft 27-item

[[Page 68212]]

HCAHPS Survey in November 2005 (70 FR 67476). The OMB approved the 
HCAHPS Survey under OMB control number 0938-0981, with an expiration 
date of December 31, 2007.

Revised Sec.  416.190(c)--Request for Review of Payment Amount

    The collection of information requirements at 5 CFR 1320 are 
applicable to requirements affecting 10 or more entities. Revised Sec.  
416.190(c) would require that a request for review of the ASC payment 
amount for insertion of an IOL must include all the information that 
CMS specifies on its Web site.
    While this section of this final rule with comment period contains 
information collection requirements, we estimate that less than 10 ASCs 
will be affected; therefore, we believe these collection requirements 
are exempt from OMB for review and approval, as specified at 5 CFR 
1320.3(c)(4). Consequently, this section of the final rule with comment 
period need not be reviewed by the OMB under the authority of the PRA.
    If you comment on any of these information collection and 
recordkeeping requirements, please mail copies directly to the 
following:

Centers for Medicare & Medicaid Services, Office of Strategic 
Operations and Regulatory Affairs, Regulations Development Group, 
Attn.: Melissa Musotto, CMS-1506-FC, Room C4-26-05, 7500 Security 
Boulevard, Baltimore, MD 21244-1850; and Office of Information and 
Regulatory Affairs, Office of Management and Budget, Room 10235, New 
Executive Office Building, Washington, DC 20503, Attn: Carolyn Lovett, 
CMS Desk Officer, (CMS-1506-FC), [email protected]. Fax (202) 
395-6974.

XXV. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, 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, when we proceed with a subsequent document(s), we will respond to 
those comments in the preamble to that document(s).

XXVI. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this final rule with comment period 
as required by Executive Order 12866 (September 1993, Regulatory 
Planning and Review), the Regulatory Flexibility Act (RFA) (September 
19, 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.
1. Executive Order 12866
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year).
    We estimate that the effects of the OPPS provisions that will be 
implemented by this final rule with comment period will result in 
expenditures exceeding $100 million in any 1 year. We estimate that 
adding 19 procedures to the ASC list and implementing section 5103 of 
Public Law 109-171 in CY 2007 will result in savings to the Medicare 
program of approximately $15 million. A more detailed discussion of the 
effects of the changes to the ASC list of procedures for CY 2007 is 
provided in section XXVI.C. below.
    In addition, we estimate that the changes that we are making in 
section XVIII. of this preamble to implement Medicare contracting 
reform mandated by section 911 of Public Law 108-173 have no economic 
effect on current Medicare payments in CY 2007. This aspect of our rule 
amends our current Medicare contractor regulations to conform them to 
the statutory changes mandated by Public Law 108-173 and in and of 
itself does not affect in any way Medicare's coverage or payment 
policies for hospital outpatient services or any other covered Medicare 
services. Accordingly, we believe that this provision has no immediate 
economic effect on Medicare payments in CY 2007.
    Further, we estimate that the changes that we are making in section 
XXII. of this preamble to implement an expanded set of quality measures 
for the IPPS Reporting Hospital Quality Data for the Annual Payment 
Update (RHQDAPU) program in accordance with sections 
1886(b)(3)(B)(viii)(III) and 1886(b)(3)(B)(viii)(IV) of the Act will 
not have a significant economic effect on Medicare payments to 
hospitals in CY 2007. A more detailed discussion of the effects of this 
provision is included in section XXII. of this preamble and section 
XXVI.E. below.
    However, we estimate the total increase (from changes in this final 
rule with comment period as well as enrollment, utilization, and case-
mix changes) in expenditures under the OPPS for CY 2007 compared to CY 
2006 to be approximately $2.24 billion. Therefore, this final rule with 
comment period is an economically significant rule under Executive 
Order 12866, and a major rule under 5 U.S.C. 804(2).
2. Regulatory Flexibility Act (RFA)
    The RFA requires agencies to determine whether a rule would have a 
significant economic impact on a substantial number of small entities. 
For purposes of the RFA, small entities include small businesses, 
nonprofit organizations, and small governmental agencies. Most 
hospitals and most other providers and suppliers are small entities, 
either by nonprofit status or by having revenues of $6 million to $29 
million in any 1 year (65 FR 69432).
    For purposes of the RFA, we have determined that approximately 37 
percent of hospitals and 73 percent of ambulatory surgery centers would 
be considered small entities according to the Small Business 
Administration (SBA) size standards. We do not have data available to 
calculate the percentages of entities in the pharmaceutical 
preparation, manufacturing, biological products, or medical instrument 
industries that would be considered to be small entities according to 
the SBA size standards. For the pharmaceutical preparation 
manufacturing industry (NAICS 325412), the size standard is 750 or 
fewer employees and $67.6 billion in annual sales (1997 business 
census). For biological products (except diagnostic) (NAICS 325414), 
with $5.7 billion in annual sales, and medical instruments (NAICS 
339112), with $18.5 billion in annual sales, the standard is 50 or 
fewer employees (see the standards Web site at: http://www.sba.gov/regulations/siccodes/). Individuals and States are not included in the 
definition of a small entity.
    Not-for-profit organizations are also considered to be small 
entities under the RFA. There are 2,167 voluntary hospitals that we 
consider to be not for-profit organizations to which this final rule 
with comment period applies.
3. Small Rural Hospitals
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a

[[Page 68213]]

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. With the exception of hospitals located in 
certain New England counties, for purposes of section 1102(b) of the 
Act, we previously defined a small rural hospital as a hospital with 
fewer than 100 beds that is located outside of a Metropolitan 
Statistical Area (MSA) (or New England County Metropolitan Area 
(NECMA)). However, under the new labor market definitions that we 
adopted in the CY 2005 final rule with comment period (consistent with 
the FY 2005 IPPS final rule), we no longer employ NECMAs to define 
urban areas in New England. Therefore, we now define a small rural 
hospital as a hospital with fewer than 100 beds that is located outside 
of an MSA. Section 601(g) of the Social Security Amendments of 1983 
(Pub. L. 98-21) designated hospitals in certain New England counties as 
belonging to the adjacent NECMA. Thus, for purposes of the OPPS, we 
classify these hospitals as urban hospitals. We believe that the 
changes to the OPPS in this final rule with comment period will affect 
both a substantial number of rural hospitals as well as other classes 
of hospitals and that the effects on some may be significant although 
the changes to the ASC payment system for CY 2007 will have no effect 
on small rural hospitals. Therefore, we conclude that this final rule 
with comment period will have a significant impact on a substantial 
number of small rural hospitals.
4. Unfunded Mandates
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 
104-4) also requires that agencies assess anticipated costs and 
benefits before issuing any rule whose mandates require spending in any 
1 year of $100 million in 1995 dollars, updated annually for inflation. 
That threshold level is currently approximately $120 million. The 
maximum nationwide cost to hospitals will be $16.9 million for HCAHPS 
(Abt Report), $58.7 million in noncapital costs for SCIP, and no cost 
for mortality measures. This final rule with comment period will not 
mandate any requirements for State, local, or tribal government, nor 
will it affect private sector costs.
5. Federalism
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it publishes any rule (proposed or final) that 
imposes substantial direct costs on State and local governments, 
preempts State law, or otherwise has Federalism implications.
    We have examined this final rule with comment period in accordance 
with Executive Order 13132, Federalism, and have determined that it 
will not have an impact on the rights, roles, and responsibilities of 
State, local or tribal governments. As reflected in Table 54, we 
estimate that OPPS payments to governmental hospitals (including State, 
local, and tribal governmental hospitals) will increase by 2.7 percent 
under this final rule with comment period. The provisions related to 
payments to ASCs in CY 2007 will not affect payments to government 
hospitals. In addition, the provisions related to MACs and HCAHPS will 
not affect payments to government hospitals.

B. Effects of OPPS Changes in This Final Rule With Comment Period

    We are making several changes to the OPPS that are required by the 
statute. We are required under section 1833(t)(3)(C)(ii) of the Act to 
update annually the conversion factor used to determine the APC payment 
rates. We are also required under section 1833(t)(9)(A) of the Act to 
revise, not less often than annually, the wage index and other 
adjustments. In addition, we must review the clinical integrity of 
payment groups and weights at least annually. Accordingly, in this 
final rule with comment period, we are updating the conversion factor 
and the wage index adjustment for hospital outpatient services 
furnished beginning January 1, 2007, as we discuss in sections II.C. 
and II.D., respectively, of this preamble. We also are revising the 
relative APC payment weights using claims data from January 1, 2005, 
through December 31, 2005, and updated cost report information. In 
response to a provision in Public Law 108-173 that we analyze the cost 
of outpatient services in rural hospitals relative to urban hospitals, 
we are continuing increased payments to rural SCHs, including EACHs. 
Section II.F. of this preamble provides greater detail on this rural 
adjustment. Finally, we are not removing any device categories from 
pass-through payment status in CY 2007.
    Under this final rule with comment period, the update change to the 
conversion factor as provided by statute will increase total OPPS 
payments by 3.4 percent in CY 2007. The expiration of the one-time wage 
reclassification under section 508 in April 2007, which is not budget 
neutral, and an increase in the fixed-dollar outlier threshold to 
account for the underestimation of outlier payments in CY 2006, results 
in a net increase of 3.0 percent. The changes to the APC weights, 
changes to the wage indices, the continuation of a payment adjustment 
for rural SCHs, and the expansion of the rural adjustment to EACHs will 
not increase OPPS payments because these changes to the OPPS are budget 
neutral. However, these updates do change the distribution of payments 
within the budget neutral system as shown in Table 54 and described in 
more detail in this section.
1. Alternatives Considered
    Alternatives to the changes we are making and the reasons that we 
have chosen these options are discussed throughout this final rule with 
comment period. Some of the major issues discussed in this final rule 
with comment period and the options considered are discussed below.
a. Alternatives Considered for Coding and Payment Policy for Visits.
    In section IX. of this preamble, we are creating five new G-codes 
for emergency department visits provided in Type B emergency 
departments and one new G-code for critical care associated with trauma 
response. Hospitals will continue using CPT codes to describe clinic 
visits and emergency department visits provided in Type A emergency 
departments. CMS instructed hospitals to report facility resources for 
clinic and emergency department visits using CPT E/M codes and to 
develop internal hospital guidelines to determine what level of visit 
to report for each patient. However, since the beginning of the OPPS, 
we have acknowledged that the CPT E/M codes do not adequately describe 
the facility resources required to perform the services. One 
alternative considered was to create G-codes to be used by hospitals to 
report clinic visits, Type A and Type B emergency department visits, 
and critical care services, which would describe hospital resource use. 
However, many commenters objected to creating G-codes before national 
guidelines were implemented. In response to this concern, we are 
finalizing new G-codes for visits provided in Type B emergency 
departments because there currently are no CPT codes that describe 
services in these facilities. In addition, we are creating one new G-
code for critical care associated with trauma response, in response to 
commenters' requests that we pay differentially for critical care 
provided with and without trauma response.
    Some hospitals have requested that they be permitted to bill 
emergency department visit codes under the OPPS for services furnished 
in a facility that meets the CPT definition for reporting

[[Page 68214]]

emergency department visit E/M codes, except that these hospitals are 
not available 24 hours a day. For CY 2007, we are establishing a set of 
codes for visits provided in dedicated emergency departments that have 
an EMTALA obligation. These codes will be billed by Type B emergency 
departments, specifically those that do not meet the Type A 
requirements. We are instructing hospitals to use current emergency 
department CPT codes to report visits provided in a specific subset of 
dedicated emergency departments, called Type A emergency departments, 
that are open 24 hours per day, 7 days per week and that do not have an 
EMTALA obligation solely based on providing at least one-third of their 
outpatient visits for the treatment of emergency medical conditions on 
an urgent basis without requiring a previously scheduled appointment. 
An alternative to this policy is to continue to uphold past policy and 
allow only the Type A subset of dedicated emergency departments to bill 
emergency department visit codes and require Type B emergency 
departments to bill clinic visit codes. However, this would not allow 
us to determine whether visits to dedicated emergency departments or 
facilities that incur EMTALA obligations but do not meet more 
prescriptive expectations that are consistent with the CPT definition 
of an emergency department have different resource costs than visits to 
either clinics or the Type A subset of dedicated emergency departments 
that meet more prescriptive expectations, including 24 hours per day, 7 
days per week availability.
    We are creating one new G-code for critical care associated with 
trauma response, in response to commenters' requests that we 
distinguish between critical care provided with and without trauma 
response. An alternative to this policy is to continue to uphold past 
policy and instruct hospitals to bill one CPT code for critical care 
services, regardless of whether the critical services were associated 
with trauma response. However, if hospitals only billed one code for 
critical care services with and without trauma activation, it would be 
difficult to pay differentially for the two services, as our claims 
data indicate is appropriate.
    We must also establish payment rates for clinic and emergency 
department visits and critical care services. For CY 2007, we are 
making payments at five payment levels for both clinic and emergency 
department visits and at two payment levels for critical care services. 
We see meaningful differences among the median costs of five levels of 
clinic and emergency department codes that suggest that five payment 
levels are more appropriate than three levels. In addition, providers 
have indicated that it is administratively burdensome to code for five 
levels, but receive payment at only three levels, as has been the 
historical policy in the OPPS. If future data indicate that three 
payment levels are more appropriate, we may revert back to three 
payment levels. For critical care, our claims data indicate that 
critical care services associated with trauma response are costlier 
than critical care services that are not associated with trauma 
response. Paying for critical care services that are associated with 
trauma response at a higher rate will lead to a more accurate 
distribution of payments. An alternative to this policy is to continue 
paying at three payment levels for both clinic and emergency department 
visits and one payment level for critical care services. However, for 
the reasons described above, we are making payment at five levels for 
clinic and emergency department visits and two levels for critical care 
services for CY 2007 to ensure that payments more accurately reflect 
the median costs of the services provided.
    For CY 2007, we are making payment for emergency visits to Type B 
dedicated emergency departments that are not part of the specific 
subset identified as Type A emergency departments at the same rate as 
clinic visits, consistent with current policy. This payment policy is 
similar to our current policy that requires services furnished in 
emergency departments that have an EMTALA obligation but do not meet 
the CPT definition of emergency department to be reported using CPT 
clinic visit E/M codes, resulting in payments based upon clinic visit 
APCs. While maintaining the same payment policy for CY 2007, the 
reporting of specific G-codes for emergency department visits provided 
in Type B dedicated emergency departments will permit us to 
specifically collect and analyze the hospital resource costs of visits 
to these facilities in order to determine whether a future proposal of 
an alternative payment policy may be warranted. An alternative would be 
to provide payment for services billed by Type B emergency departments 
at payment rates other than the clinic visit rates. However, we do not 
know what the hospital facility costs of these visits would be because 
we are unable to identify these services in our historical claims data. 
In some respects, their costs may resemble the costs of visits to 
clinics because they may not be available 24 hours per day or may not 
require the same high state of readiness as Type A emergency 
departments. In other respects, their costs may resemble the costs of 
visits to Type A emergency departments because they both provide 
predominantly unscheduled visits. Therefore, we currently have no 
accurate methodology for establishing payment rates that are 
appropriate for visits to Type B emergency departments. Therefore, 
consistent with past payment policies for certain services, such as 
drug administration, in which we maintained consistent payment policies 
while gathering more detailed cost data, we are continuing payment to 
Type B emergency departments at clinic visit rates while we gather 
hospital claims data specific to these visits to review their costs.
b. Alternatives Considered for Brachytherapy Source Payments
    Pursuant to sections 1833(t)(2)(H) and 1833(t)(16)(C) of the Act, 
we have paid for brachytherapy sources furnished on or after January 1, 
2004, and before January 1, 2007, on a per source basis at an amount 
equal to the hospital's charge adjusted to cost by application of the 
hospital-specific overall CCR. For CY 2007, we are making payment for 
brachytherapy sources at a prospectively determined rate for each 
source for which we have claims data, and each source is assigned to 
its own APC. We are converting the median cost to a relative weight by 
dividing it by the median for APC 0606, scaling the unscaled weight for 
budget neutrality, and multiplying the scaled weight by the conversion 
factor to calculate the payment rate per source. This is our standard 
OPPS methodology for using median costs to calculate the payment for 
each APC.
    The first alternative we considered was to establish a per day 
payment for brachytherapy sources based on our CY 2005 claims data. 
While this alternative would be consistent with the philosophy of a 
prospective payment system and would mitigate the effects on payment of 
inaccurate coding of the number of sources used, we believe that a per 
day payment may not provide source payment specifically addressed to 
the hospital resources used under the unique clinical circumstances of 
each individual treatment because of the variation in the number of 
sources required to treat patients under different clinical conditions. 
There is considerable clinical variation in the number of sources used 
for brachytherapy services, and we believe a per day payment based on 
an average

[[Page 68215]]

number of sources used may not as accurately reflect the resources used 
for an individual Medicare beneficiary's treatment as the per source 
payment methodology. Therefore, we are not setting payments on a per 
day basis.
    The second alternative we considered was to continue to make 
separate payment for sources of brachytherapy under the current 
methodology of hospital charges reduced to costs. Although hospitals 
are familiar with this methodology and this alternative is consistent 
with the requirement that sources be paid separately, we believe that 
to continue to pay on this basis would be inconsistent with the general 
methodology of a prospective payment system and would provide no 
incentive for a hospital to provide services efficiently and at the 
lowest cost.
    The third alternative we considered and are accepting for CY 2007 
is to make payment for each brachytherapy source on a per source rate 
that is calculated using our standard OPPS methodology. This is 
consistent with our methodology for setting payment rates for other 
services and is consistent with the expiration of the Public Law 108-
173 requirement that payment for sources of brachytherapy be made at 
charges reduced to cost for dates of service on and after January 1, 
2004, through December 31, 2006. Moreover, for the reasons we discuss 
in detail in section VII. of this final rule with comment period, we 
believe that this option will provide the most appropriate payment for 
brachytherapy sources.
c. Alternatives Considered for Payment of Radiopharmaceuticals
    In developing the payment policy for separately payable 
radiopharmaceuticals for this CY 2007 final rule with comment period, 
we considered three policy options.
    The first alternative we considered was to package additional 
radiopharmaceuticals, either through packaging payments for all 
radiopharmaceuticals with payments for the services with which they are 
billed or setting a packaging threshold established specifically for 
radiopharmaceuticals that was much higher than the $55 threshold 
proposed for other drugs and biologicals. In contrast to other 
separately payable drugs where the administration of many drugs is 
reported with only a few drug administration HCPCS codes, only a small 
number of specific radiopharmaceuticals may be appropriately provided 
in the performance of each particular nuclear medicine procedure. 
Because the provision of nuclear medicine procedures always requires 
one or more radiopharmaceuticals, packaging more radiopharmaceuticals 
effectively would result in some increases in the associated nuclear 
medicine procedure APC payment rates. A policy to package additional 
radiopharmaceuticals would be consistent with the OPPS packaging 
principles and payment policies which generally provide appropriate 
payment for the ``average'' service and would provide greater 
administrative simplicity for hospitals. However, packaging the costs 
of all radiopharmaceuticals into the procedures in which they are used 
could result in inadequate payment for the highest cost products.
    The second alternative that we considered for CY 2007 would have 
established prospective payment rates for separately payable 
radiopharmaceuticals using mean costs derived from the CY 2005 claims 
data, where the costs are determined using our standard methodology of 
applying hospital-specific departmental CCRs to radiopharmaceutical 
charges and defaulting to hospital-specific overall CCRs only if 
appropriate departmental CCRs are unavailable. This policy would have 
established our packaging threshold for radiopharmaceuticals at $55, 
the same as the packaging threshold for drugs and biologicals under the 
CY 2007 OPPS. We did not select this option because commenters 
indicated that changes to many radiopharmaceutical HCPCS codes in CY 
2006 were made because hospitals were having difficulty with the CY 
2005 codes, and, therefore, the CY 2005 hospital claims data were not 
accurate and not applicable to the CY 2006 codes.
    The third alternative that we considered and have selected for CY 
2007 is to continue the temporary CY 2006 methodology of paying for 
separately payable radiopharmaceuticals at charges reduced to cost, 
where payment would be determined using each hospital's overall CCR, 
and establishing our radiopharmaceutical packaging threshold at $55, as 
we are doing for other drugs for the CY 2007 OPPS. This policy provides 
stability to the payment methodology for radiopharmaceuticals from CY 
2006 to CY 2007. As we indicated for CY 2006, this payment methodology 
provides an acceptable proxy for the average acquisition of the 
radiopharmaceutical along with its handling cost. We intend this 
methodology to be a temporary measure until we have confidence in the 
coding and charging practices of hospitals under the HCPCS codes that 
were new for CY 2006.
2. Limitations of Our Analysis
    The distributional impacts presented here are the projected effects 
of the policy changes, as well as the statutory changes that will be 
effective for CY 2007, on various hospital groups. We estimate the 
effects of individual policy changes by estimating payments per service 
while holding all other payment policies constant. We use the best data 
available but do not attempt to predict behavioral responses to our 
policy changes. In addition, we do not make adjustments for future 
changes in variables such as service volume, service-mix, or number of 
encounters. As we have done in previous rules, we solicited comments 
and information about the anticipated effect of the proposed changes on 
hospitals and our methodology for estimating them. Comments on the 
impact of the proposed changes for CY 2007 are included in the 
discussion of the applicable topics in the preamble of this final rule 
with comment period. There were no comments on the methodology we 
proposed to use to evaluate the impact of the proposed changes other 
than those discussed under applicable issues.
3. Estimated Impacts of This Final Rule With Comment Period on 
Hospitals
    The estimated increase in the total payments made under the OPPS is 
limited by the increase to the conversion factor set under the 
methodology in the statute. The distributional impacts presented do not 
include assumptions about changes in volume and service-mix. The 
enactment of Public Law 108-173 on December 8, 2003, provided for the 
additional payment outside of the budget neutrality requirement for 
wage indices for specific hospitals reclassified under section 508 
through CY 2007. Table 54 shows the estimated redistribution of 
hospital payments among providers as a result of a new APC structure, 
wage indices, and adjustment for rural SCHs (which includes EACHs), 
which are budget neutral; the estimated distribution of increased 
payments in CY 2007 resulting from the combined impact of the APC 
recalibration, wage effects, the rural SCH adjustment, and the market 
basket update to the conversion factor; and, finally, estimated 
payments considering all payments for CY 2007 relative to all payments 
for CY 2006, including the impact of expiring wage provisions and 
changes in the outlier threshold. Because updates to the conversion

[[Page 68216]]

factor, including the update of the market basket and the addition of 
money not dedicated to pass-through payments, are applied uniformly, 
observed redistributions of payments in the impact table largely depend 
on the mix of services furnished by a hospital (for example, how the 
APCs for the hospital's most frequently furnished services would 
change), the impact of the wage index changes on the hospital, and the 
impact of the payment adjustment for rural SCHs, including EACHs. 
However, total payments made under this system and the extent to which 
this final rule with comment period will redistribute money during 
implementation also will depend on changes in volume, practice 
patterns, and the mix of services billed between CY 2006 and CY 2007, 
which CMS cannot forecast. Overall, the final OPPS rates for CY 2007 
will have a positive effect for all hospitals paid under the OPPS. 
Changes will result in a 3.0 percent increase in Medicare payments to 
all hospitals, exclusive of transitional pass-through payments. 
Removing cancer and children's hospitals because their payments are 
held harmless to the pre-BBA ratio between payment and cost suggests 
that changes will result in a 3.0 percent increase in Medicare payments 
to all other hospitals.
    To illustrate the impact of the final CY 2007 changes, our analysis 
begins with a baseline simulation model that uses the final CY 2006 
weights, the FY 2006 final post-reclassification IPPS wage indices 
without additional increases resulting from section 508 
reclassifications, and the final CY 2006 conversion factor. Column 2 in 
Table 54 reflects the independent effects of the APC reclassification 
and recalibration changes. Column 3 reflects the effects of updated 
wage indices, including the new occupational mix data described in the 
FY 2007 IPPS final rule, and the adjustment for rural SCHs and EACHs. 
The clarification that the rural adjustment applies to EACHs is not 
shown separately because there are so few EACHs that the overall impact 
cannot be observed when payments are aggregated by type of hospital. 
These effects are budget neutral, which is apparent in the overall zero 
impact in payment for all hospitals in the top row. Column 2 shows the 
independent effect of changes resulting from the reclassification of 
services codes among APC groups and the recalibration of APC weights 
based on a complete year of CY 2005 hospital OPPS claims data and more 
recent cost report data. We modeled the independent effect of APC 
recalibration by varying only the weights, the final CY 2006 weights 
versus the final CY 2007 weights in our baseline model, and calculating 
the percent difference in payments.
    Column 3 shows the impact of updating the wage index used to 
calculate payment by applying the FY 2007 IPPS wage index, combined 
with the impact of the 7.1 percent rural adjustment for SCHs and EACHs 
for services other than drugs, biologicals, brachytherapy sources, and 
those receiving pass-through payments. The OPPS wage index used in 
Column 3 does not include changes to the wage index for hospitals 
reclassified under section 508 of Public Law 108-173. We modeled the 
independent effect of updating the wage index and the rural adjustment 
by varying only the wage index and the inclusion of EACHs, using the CY 
2007 scaled weights, and a CY 2006 conversion factor that included a 
budget neutrality adjustment for changes in wage effects and the rural 
adjustment between CY 2006 and CY 2007.
    Column 4 demonstrates the combined ``budget neutral'' impact of 
proposed APC recalibration, the wage index update, and the rural 
adjustment for rural SCHs and EACHs on various classes of hospitals, as 
well as the impact of updating the conversion factor with the market 
basket update. We modeled the independent effect of budget neutrality 
adjustments and the market basket update by using the weights and wage 
indices for each year, and using a CY 2006 conversion factor that 
included the proposed market basket update and budget neutrality 
adjustments for differences in wages and the adjustment for rural SCHs 
and EACHs.
    Finally, Column 5 depicts the full impact of the final CY 2007 
policy on each hospital group by including the effect of all the 
changes for CY 2007 and comparing them to all estimated payments in CY 
2006, including those required by Public Law 108-173. Column 5 shows 
the combined budget neutral effects of Columns 2 through 4, plus the 
impact of increasing the outlier threshold after realigning the overall 
CCR calculation used to model the outlier threshold with the one used 
by the fiscal intermediaries for payment, the impact of changing the 
percentage of total payments dedicated to transitional pass-through 
payments to 0.21 percent, and the expiration of payment for wage index 
increases for hospitals reclassified under section 508 of Public Law 
108-173 in April 2007. As noted in section II.D. of this preamble, 
because section 508 expires in April 2007 and OPPS operates on a 
calendar year basis, we used a blended wage index consisting of 25 
percent of the IPPS wage index with section 508 and 75 percent of the 
IPPS wage index after section 508 expires.
    We modeled the independent effect of all changes in Column 5 using 
the final weights for CY 2006 and the final weights for CY 2007. The 
wage indices in each year include wage index increases for hospitals 
eligible for reclassification under section 508 of Public Law 108-173, 
and in 2007, these provisions expire in April 2007. We used the final 
conversion factor for CY 2006 of $59.511 and the final CY 2007 
conversion factor of $61.468. Column 5 also contains simulated outlier 
payments for each year. We used the charge inflation factor used in the 
FY 2007 IPPS rule of 7.57 percent (1.0757) to increase individual costs 
on the CY 2005 claims to reflect CY 2006 dollars, and we used the most 
recent overall CCR for each hospital as calculated for the APC median 
setting process. Using the CY 2005 claims and a 7.57 percent charge 
inflation factor, we currently estimate that actual outlier payments 
for CY 2006, using a multiple threshold of 1.75 and a fixed-dollar 
threshold of $1,250 would be 1.25 percent of total payments, which is 
0.25 percent higher than the 1.0 percent that we projected in setting 
outlier policies for CY 2006, due to the differences in the calculation 
of the overall CCR, as discussed in section II.A.1.c. of this preamble. 
Outlier payments of 1.25 percent appear in the CY 2006 comparison in 
Column 5. We used the same set of claims and a charge inflation factor 
of 15.15 percent (1.1515) to model the CY 2007 outliers at 1.0 percent 
of total payments using a multiple threshold of 1.75 and a fixed-dollar 
threshold of $1,825.

Column 1: Total Number of Hospitals

    Column 1 in Table 54 shows the total number of hospital providers 
(3,992) for which we were able to use CY 2005 hospital outpatient 
claims to model CY 2006 and CY 2007 payments by classes of hospitals. 
We excluded all hospitals for which we could not accurately estimate CY 
2006 or CY 2007 payment and entities that are not paid under the OPPS. 
The latter entities include CAHs, all-inclusive hospitals, and 
hospitals located in Guam, the U.S. Virgin Islands, Northern Marianas, 
American Samoa, and the State of Maryland. This process is discussed in 
greater detail in section II.A. of this preamble. At this time, we are 
unable to calculate a disproportionate share (DSH) variable for 
hospitals not participating in the IPPS. Hospitals for which we do not 
have a DSH variable are grouped separately and generally include

[[Page 68217]]

psychiatric hospitals, rehabilitation hospitals, and LTCHs. Finally, 
section 1833(t)(7)(D) of the Act permanently holds harmless cancer 
hospitals and children's hospitals to the proportion of their pre-BBA 
payment relative to their costs. Because this final rule with comment 
period will not impact these hospitals negatively, we removed them from 
our impact analyses. We show the total number (3,928) of OPPS 
hospitals, excluding the hold-harmless cancer hospitals and children's 
hospitals, on the second line of the table.

Column 2: APC Recalibration

    The combined effects of the APC reclassification and recalibration, 
in Column 2 are typical for APC recalibration. Overall, these changes 
increase payments to urban hospitals by 0.1 percent, although some 
classes of urban hospitals experience decreases in payments. However, 
changes to the APC structure for CY 2007 tend to favor, slightly, urban 
hospitals. We estimate that large urban hospitals would see a 0.1 
percent decrease, while ``other'' urban hospitals experience an 
increase of 0.2 percent.
    Overall, rural hospitals show a modest 0.3 percent decrease as a 
result of changes to the APC structure. Notwithstanding a modest 
overall increase in payments, there is substantial variation among 
classes of rural hospitals. The lowest volume hospitals experience the 
largest decrease of 3.0 percent. Rural hospitals with greater than 
5,000 lines of volume demonstrate no change or decreases of no more 
than 0.4 percent as a result of APC recalibration.
    Among other classes of hospitals, the largest observed impacts 
resulting from APC recalibration include an increase of 0.2 percent for 
minor teaching hospitals and a decrease of 0.3 percent for major 
teaching hospitals. Urban hospitals that are treating DSH patients and 
are also teaching hospitals experience an increase of 0.1 percent. We 
project that hospitals for which a DSH percentage is not available, 
including psychiatric hospitals, rehabilitation hospitals, and long-
term care hospitals, will experience decreases in payments of 7.2 
percent, and for the urban subset, 7.4 percent.
    Classifying hospitals by type of ownership suggests that 
proprietary hospitals would gain 0.2 percent, governmental hospitals 
would experience losses of 0.1 percent, and voluntary hospitals would 
experience no change.

Column 3: New Wage Indices and the Effect of the Rural Adjustment

    Changes introduced by the FY 2007 IPPS wage indices together with 
the effect of including EACHs in the rural adjustment would have a 
modest impact in CY 2007, with no changes to payments to rural 
hospitals other than SCHs, a decrease of 0.1 percent for large urban 
hospitals, and an increase to other urban hospitals of 0.1 percent. We 
estimate that rural SCHs will experience an increase in payments of 0.1 
percent, while all other rural hospitals experience no change. With 
respect to volume, rural hospitals with fewer than 11,000 lines and 
21,000-42,999 lines experience increases of 0.1 to 0.9 percent. For 
both facility size and volume, no category of rural hospitals 
experiences an increase greater than 0.9 percent.
    Overall, urban hospitals experience no change in payments as a 
result of the new wage indices and the rural adjustment. However, large 
urban hospitals experience a decrease of 0.1 percent and other urban 
hospitals experience an increase of 0.1 percent. When categorized by 
volume, urban hospitals with the largest volume experience no change in 
payment as a result of changes to the wage index and the presence of 
the rural adjustment, and urban hospitals with volumes less than 42,999 
lines experience decreases in payment from 0.1 percent to 0.7 percent.
    Looking across other categories of hospitals, we estimate that 
updating the wage index and continuing the rural adjustment will lead 
major teaching hospitals to gain 0.1 percent, and hospitals with minor 
graduate medical education programs are estimated to experience no 
change. Hospitals serving more than 35 percent low-income patients are 
estimated to experience a decrease of 0.1 percent. Hospitals serving no 
low-income patients are expected to see an increase of 0.2 percent, 
while hospitals for which the percent of low-income patients cannot be 
determined are expected to lose 0.4 percent. Voluntary hospitals as 
classes would experience an increase of 0.1 percent change in payment 
due to wage changes and the effect of the rural adjustment. 
Governmental and proprietary hospitals will lose 0.1 and 0.3 percent, 
respectively.

Column 4: All Budget Neutrality Changes and Market Basket Update

    The addition of the market basket update alleviates any negative 
impacts on payments for CY 2007 created by the budget neutrality 
adjustments made in Columns 2, and 3, with the exception of urban 
hospitals with the lowest volume of services and hospitals not paid 
under the IPPS, including psychiatric hospitals, rehabilitation 
hospitals, and LTCHs (DSH not available). In many instances, the 
redistribution of payments created by APC recalibration offsets those 
introduced by updating the wage indices. However, in a few instances, 
negative APC recalibration changes compound a reduction in payment from 
updating the wage index.
    We estimate that the cumulative impact of the budget neutrality 
adjustments and the addition of the market basket update would result 
in an increase in payments for urban hospitals of 3.5 percent, which is 
0.1 percent higher than the market basket update of 3.4 percent. Large 
urban hospitals will experience an increase of 3.2 percent and other 
urban hospitals will experience an increase of 3.8 percent. Urban 
hospitals with the lowest volume experience a negative market basket 
update of 1.4 percent. Urban hospitals with volumes greater than 5,000 
lines have increases from 1.8 percent to 3.5 percent.
    We estimate that the cumulative impact of budget neutrality 
adjustments and the market basket update will result in an overall 
increase for rural hospitals of 3.2 percent, with rural SCHs 
experiencing an update of 3.3 percent and other rural hospitals also 
experiencing an update of 3.1 percent. In general, rural hospitals with 
more than 5,000 lines of volume experience increases equal to or 
greater than 3.1 percent. We estimate that low-volume rural hospitals 
would experience an increase of 0.9 percent.
    The changes across columns for other classes of hospitals are 
fairly moderate and most show updates relatively close to the market 
basket update with the exception of hospitals not paid under the IPPS, 
which show negative payment updates. Voluntary and proprietary 
hospitals also show an increase equal to or greater than the market 
basket. Governmental hospitals show an increase of 3.2 percent.

Column 5: All Changes for CY 2007

    Column 5 compares all changes for CY 2007 to final payment for CY 
2006 and includes any additional dollars resulting from provisions in 
Public Law 108-173 in both years, changes in outlier payment 
percentages and thresholds, and the difference in pass-through 
estimates. Overall, we estimate that hospitals will gain 3.0 percent 
under this final rule with comment period in CY 2007 relative to total 
spending in CY 2006. When we

[[Page 68218]]

excluded cancer and children's hospitals, which are held harmless, the 
gain remains 3.0 percent. Hospitals will receive the 3.4 percent 
increase due to the market basket update appearing in Column 4. 
However, they lose 0.04 percent due to the increase in the pass-through 
estimate between CY 2006 and CY 2007. Moreover, we estimate that 
hospitals also experience a 0.25 percent loss due to outlier payments 
as a result of the increased threshold and the change to the overall 
CCR that is used to estimate outlier payments. In addition, there is a 
loss of 0.17 percent as a result of the expiration of the section 508 
wage adjustment.
    In general, urban hospitals appear to experience the largest gains 
from the combined effects of these factors. We estimate that, overall, 
urban hospitals will gain 3.1 percent. We estimate that hospitals in 
large urban areas will gain 2.9 percent in CY 2007, and hospitals in 
other urban areas will gain 3.2 percent. We estimate that low-volume 
urban hospitals will experience a decrease in total payments of 1.2 
percent between CY 2006 and CY 2007.
    Overall, rural hospitals experience increases that are lower than 
those observed for urban hospitals. Overall, we estimate that rural 
hospitals will experience an increase in payments of 2.7 percent. We 
also estimate that rural SCHs and other rural hospitals will experience 
an increase of 2.6 percent and 2.8 percent, respectively. Rural 
hospitals with volumes greater than 4,999 lines experience increases of 
at least 2.7 percent. We project that low-volume rural hospitals will 
experience the greatest decrease in overall payment of 0.9 percent.
    Among other classes of hospitals, we estimate that hospitals not 
paid under the IPPS (DSH Not Available) will experience decreases in 
payments between CY 2006 and CY 2007 of 4.0 percent. We estimate that 
major teaching hospitals will experience an increase of 2.8 percent and 
that nonteaching hospitals will experience an increase of 3.0 percent.
BILLING CODE 4120-01-P

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[GRAPHIC] [TIFF OMITTED] TR24NO06.030


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BILLING CODE 4120-01-C
4. Estimated Effect of This Final Rule With Comment Period on 
Beneficiaries
    For services for which the beneficiary pays a copayment of 20 
percent of the payment rate, the beneficiary share of payment would 
increase for services for which OPPS payments will rise and would 
decrease for services for which OPPS payments would fall. For example, 
for an electrocardiogram (APC 0099), the minimum unadjusted copayment 
in CY 2006 was $4.49. In this final rule with comment period, the 
minimum unadjusted copayment for APC 0099 is $4.66 because the OPPS 
payment for the service will increase under this final rule with 
comment period. In another example, for a Level IV Needle Biopsy (APC 
0037), in the CY 2006 OPPS, the national unadjusted copayment was 
$228.76, and the minimum unadjusted copayment was $114.38. In this 
final rule with comment period, the national unadjusted copayment for 
APC 0037 is $228.76. The minimum unadjusted copayment for APC 0037 is 
$126.20, or 20 percent of the payment for APC 0037. In all cases, the 
statute limits beneficiary liability for copayment for a service to the 
inpatient hospital deductible for the applicable year. For CY 2007, the 
inpatient deductible is $992.
    In order to better understand the impact of changes in copayment on 
beneficiaries, we modeled the percent change in total copayment 
liability using CY 2005 claims. We estimate, using the claims of the 
3,992 hospitals on which our modeling is based, that total beneficiary 
liability for copayments will decline as an overall percentage of total 
payments from 27.5 percent in CY 2006 (revised from the 29 percent that 
we estimated for CY 2006 in the CY 2006 OPPS final rule with comment 
period 70 FR 68727) to 26.6 percent in CY 2007. This estimated decline 
in beneficiary liability is a consequence of the APC recalibration and 
reconfiguration we are making for CY 2007.
5. Conclusion
    The changes in this final rule with comment period will affect all 
classes of hospitals. Some hospitals experience significant gains and 
others less significant gains, but almost all hospitals will experience 
positive updates in OPPS payments in CY 2007. Table 54 demonstrates the 
estimated distributional impact of the OPPS budget neutrality 
requirements and an additional 3.0 percent increase in payments for CY 
2007, after considering the market basket increase, the cost of 
outliers, changes to the pass-through estimate and the elimination of 
the section 508 adjustment of Public Law 108-173. The accompanying 
discussion, in combination with the rest of this final rule with 
comment period constitutes a regulatory impact analysis.
6. Accounting Statement
    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf, in Table 55 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the CY 2007 OPPS provisions of this final 
rule with comment period. This table provides our best estimate of the 
increase in Medicare payments under the OPPS as a result of the 
provisions presented in this final rule with

[[Page 68222]]

comment period for CY 2007. All expenditures are classified as 
transfers.

  Table 55.--Accounting Statement: Classification of Estimated CY 2007
     OPPS Expenditures Associated With CY 2007 Final Rule Provisions
------------------------------------------------------------------------
                Category                            Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers.........  $620 Million.
From Whom to Whom......................  Federal Government to OPPS
                                          Medicare Providers.
Annualized Monetized Transfer..........  $150 Million.
From Whom to Whom......................  Premium Payments from
                                          Beneficiaries to Federal
                                          Government.
    Total..............................  $470 Million.
------------------------------------------------------------------------

C. Effects of Changes to the ASC Payment System for CY 2007

    We are adding 19 surgical procedures to the ASC list of Medicare 
payable procedures for CY 2007. We are also implementing section 5103 
of Public Law 109-171 and sections 1834(d)(2) and (d)(3) of the Act. 
Section 5103 of Public Law 109-171 requires the Secretary to substitute 
the OPPS payment amount for the ASC standard overhead amount if the 
standard overhead amount for facility services for surgical procedures 
performed in an ASC, without application of any geographic adjustment, 
exceeds the Medicare OPPS payment amount for the service for that year, 
without application of any geographic adjustment. The OPPS cap on ASC 
payment rates applies to surgical procedures furnished in ASCs on or 
after January 1, 2007, and before the effective date of the revised ASC 
payment system. Except for the payment changes required under section 
5103 of Public Law 109-171, we are not making any changes in CY 2007 to 
the ASC payment rates that are currently in effect.
    Sections 1834(d)(2) and (d)(3) of the Act require that the computed 
beneficiary coinsurance amount for screening flexible sigmoidoscopy and 
screening colonoscopy services provided in hospital outpatient 
departments and ASCs be equal to 25 percent of the payment amount. They 
also require Medicare to pay the lesser of the ASC or OPPS rate for 
those screening services in each geographic area. For CY 2007, the OPPS 
rate will be limited to the lesser ASC rate for screening 
colonoscopies. Medicare payment for screening sigmoidoscopies will not 
be affected in CY 2007 because those services are not currently 
provided in ASCs. There will be no effect on the fee paid to ASCs for 
screening colonoscopies. However, beginning in CY 2007, beneficiaries 
will be responsible for a 25 percent coinsurance for screening 
colonoscopies when provided in ASCs, as they have been for the services 
provided in hospital outpatient departments.
    Except for the payment changes required under section 5103 of 
Public Law 109-171 and sections 1834(d)(2) and (d)(3) of the Act, we 
are not making any changes in CY 2007 to the ASC payment rates that are 
currently in effect.
    CMS estimates that adding the 19 procedures discussed in section 
XVII. of this preamble and implementing the Public Law 109-171 mandate 
will result in a savings to the Medicare program of approximately $15 
million in CY 2007.
1. Alternatives Considered
    We are issuing this final rule with comment period to meet a 
statutory requirement that we update the list of approved ASC 
procedures at least every 2 years. We implement the biennial update of 
the list through notice and comment in the Federal Register to give 
interested parties an opportunity to review and comment on proposed 
additions to and deletions from the ASC list. The last update of the 
ASC list through notice and comment was effective July 5, 2005. 
However, the statute requires us to update the list at least every 2 
years, which means we must update the list by July 2007.
2. Limitations of Our Analysis
    Without datasets related to classes of ASCs which parallel the data 
maintained in the Medicare provider-specific files for hospitals, we 
cannot model distributional impacts of the CY 2007 changes in the ASC 
list and ASC payments similar to those we prepare for our OPPS impact 
analysis (see Table 54). The actuarial estimate of Medicare program 
costs or savings resulting from the update of the ASC list and 
implementation of section 5103 of Public Law 109-171 and sections 
1834(d)(2) and (d)(3) of the Act in CY 2007 is based on estimated CY 
2007 utilization. As we have done in previous rules, we solicited 
comments and information about the anticipated effect of these changes 
that we proposed for CY 2007 to gauge their impact on individual ASCs, 
but we received no comments on the subject.
3. Estimated Effects of This Final Rule With Comment Period on ASCs
    CMS estimates that approximately 25 percent of the cases currently 
reported by hospitals for each of the 19 codes we are adding to the ASC 
list will shift to the ASC setting in CY 2007. We estimate that the 
shift of these procedures to the less costly ASC setting will result in 
modest savings for the Medicare program.
    Savings will also be realized because section 5103 of the Public 
Law 109-171 will impose a payment limit for 275 procedures on the CY 
2007 ASC list. The Office of the Actuary estimates that adding 19 
surgical procedures to the ASC list and capping payment for 275 
procedures on the current ASC list will result in a combined savings to 
the Medicare program of approximately $15 million in CY 2007. We have 
not estimated the impact of our changes for CY 2007 on Medicare 
expenditures in subsequent years because we have proposed to implement 
an entirely revised payment system in CY 2008.
    Currently, Medicare pays a facility fee to ASCs only for those 
procedures that have been approved for the ASC list. The addition of 19 
surgical procedures to the ASC list will be beneficial to ASCs by 
making it possible for them to offer more surgical procedures to 
Medicare beneficiaries. We believe that approximately 25 percent of the 
annual hospital outpatient volume of the 19 procedures added to the ASC 
list will move to the ASC setting in CY 2007. To the extent that 
hospital outpatient utilization decreases and ASC utilization increases 
in CY 2007, the Medicare program will realize a savings because the ASC 
standard overhead amount for all procedures, including the proposed 
additions to the ASC list, will be equal to or lower than the payment 
rate for the same procedures under the OPPS. Because hospitals perform 
a much higher volume of ambulatory

[[Page 68223]]

surgeries overall than are performed in ASCs, we do not expect 
significant hospital revenue losses to result from migration of 
procedures that we are adding to the ASC list to the ASC setting.
4. Estimated Effects of This Final Rule With Comment Period on 
Beneficiaries
    The changes for CY 2007 will be positive for beneficiaries in at 
least two respects. First, with the exception of screening 
colonoscopies, beneficiary coinsurance for ASC facility services is set 
at 20 percent, which is generally lower than the OPPS coinsurance rate, 
which can range from 20 percent to 40 percent. In addition, in 
accordance with section 5103 of Public Law 109-171, no ASC payment rate 
in CY 2007 may be greater than the OPPS rate for a given procedure. 
Thus, due to the limitations on the ASC facility rate required by 
Public Law 109-171, beneficiaries will be assured a lower ASC 
coinsurance amount for more procedures in CY 2007 than in previous 
years.
    Second, beneficiary access to services will be expanded by the 
addition of 19 surgical procedures to the ASC list. Beneficiaries will 
have an additional setting from which to choose were it necessary for 
them to undergo one of the surgical procedures that we are adding to 
the ASC list in CY 2007.
    Beneficiary coinsurance for screening colonoscopies performed in an 
ASC will increase from 20 percent to 25 percent beginning in CY 2007, 
which is the same coinsurance rate applicable to screening 
colonoscopies under the OPPS. This coinsurance rate is legislated. 
However, we do not believe that this coinsurance increase will 
materially affect access to screening colonoscopies performed in ASCs.
5. Conclusion
    The impact on ASCs of changes to the ASC payment system for CY 2007 
will depend on an individual ASC's mix of patients and its payers, 
specifically, the proportion of its patients who are Medicare 
beneficiaries, whether or not the ASC chooses to perform the procedures 
added to the ASC list, and whether or not the ASC provides services 
that will be affected by the payment limits imposed by section 5103 of 
Public Law 109-171. Overall, the Office of the Actuary estimates that 
the Medicare program will realize a $15 million savings as a result of 
implementing the changes for CY 2007.
6. Accounting Statement
    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 56 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the CY 2007 ASC provisions of this final 
rule with comment period. This table provides our best estimate of the 
reduction in Medicare payments under the ASC payment system as a result 
of the provisions presented in this final rule with comment period for 
CY 2007. All expenditures are classified as transfers.

Table 56.--Accounting Statement: Classification of Estimated CY 2007 ASC
       Expenditures Associated With CY 2007 Final Rule Provisions
------------------------------------------------------------------------
                Category                            Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers.........  -$15 Million.
From Whom to Whom......................  Federal Government to ASC
                                          Medicare Providers.
Annualized Monetized Transfer..........  -$4 Million.
From Whom to Whom......................  Premium Payments from
                                          Beneficiaries to Federal
                                          Government.
                                        --------------------------------
    Total..............................  -$11 Million.
------------------------------------------------------------------------

D. Effects of the Medicare Contracting Reform Mandate

    In section XVIII. of this preamble, we discuss our revision of the 
regulations under 42 CFR Part 421, Subpart B for Medicare 
intermediaries and carriers to conform the regulations to the statutory 
changes mandated by section 1874A of the Act as added by section 911 of 
Public Law 108-173, which took effect on October 1, 2005. As discussed 
in section XVIII. of this preamble, section 1874A of the Act is 
intended to improve Medicare's administrative services to beneficiaries 
and health care providers and to bring standard contracting principles 
to Medicare, such as competition and performance incentives, which the 
government has long applied to other Federal programs under the FAR. 
This provision requires that CMS replace its current claims payment 
contractors by October 1, 2011, with new contract entities referred to 
as MACs. We believe that this provision has no immediate economic 
effect on Medicare payments in CY 2007 because it is administrative in 
nature and does not change Medicare's coverage and reimbursement 
policies for hospital outpatient services or any other covered Medicare 
services.

E. Effects of Additional Quality Measures and Procedures for Hospital 
Reporting of Quality Data for IPPS FY 2008

    We have tried to minimize the costs of HCAHPS, including minimizing 
the impact on small/rural hospitals. While there are no capital or 
operational/maintenance costs associated with the implementation of 
HCAHPS, there are costs for collecting the data. The nationwide costs 
of conducting the HCAHPS survey are estimated to be between $3.6 
million and $16.9 million per year, assuming approximately 3,700 
hospitals (see Abt Associates, Inc. report, http://www.cms.hhs.gov/HospitalQualityInits/downloads/HCAHPSCostsBenefits200512.pdf).
    Hospitals that are self-administering the survey (or their survey 
vendor, if the hospital chooses to employ one) beginning in 2007 will 
participate in free HCAHPS training offered via Webinar in January 
2007. All hospitals that join in 2007 will be required to participate 
in a month-long dry run in March 2007. Hospitals that chose not to 
participate in HCAHPS will not meet the HCAHPS requirements necessary 
to receive the full market basket update for FY 2008.
    The costs of collecting HCAHPS patient survey data will vary across 
hospitals depending on the method used to collect patient survey data, 
the number of patients surveyed, and whether HCAHPS is incorporated 
into their existing patient satisfaction surveys. While hospitals may 
choose to administer HCAHPS as a stand-alone survey, there are 
significant cost savings associated with combining HCAHPS with existing 
surveys.
    We have cited a cost/benefit report showing that the costs of 
conducting HCAHPS would be as follows. HCAHPS collected as a separate 
survey is

[[Page 68224]]

between $11.00 and $15.25 per complete survey ($3,300 to $4,575 per 
hospital), assuming that 80-85 percent of hospitals collect HCAHPS by 
mail and the remainder by phone or active IVR. It would be considerably 
less expensive to combine HCAHPS with existing surveys. In a combined 
survey, it is estimated that it will cost only $3.26 per complete 
survey (or $978 per hospital) to incorporate the 27-item HCAHPS 
instrument into existing surveys. Depending on the proportion of 
hospitals that incorporate HCAHPS into existing surveys, it is 
therefore estimated that the costs of HCAHPS is between $3.6 million 
and $16.9 million per year (Abt Associates, Inc. report, http://www.cms.hhs.gov/HospitalQualityInits/downloads/HCAHPSCostsBenefits200512.pdf).
    We have made provisions to reduce the burden of the HCAHPS 
initiative for small/rural hospitals. As a cost savings provisions for 
all hospitals (but one that is particularly useful for small 
hospitals), a free on-line tool for data entry is available to 
hospitals choosing to conduct data entry themselves in lieu of 
contracting with a survey vendor for this service. The sample size 
requirements are reduced for small hospitals unable to achieve 300 
completed surveys. For all hospitals, we are allowing four modes of 
survey administration (mail, telephone, combination of mail and 
telephone, and active interactive voice recognition), and we are 
allowing for hospitals to either use a vendor or conduct the survey on 
their own. Additionally, we are allowing hospitals to integrate the 
HCAHPS survey with their own patient satisfaction surveys. This option 
provides significant cost savings to conduct HCAHPS annually: for the 
mail mode, it is estimated to cost $603 per hospital; and for the 
telephone mode, it is estimated to be $2,478 per hospital. For 
hospitals collecting 100 completed surveys, it costs about $326 
annually per hospital. CMS is providing free HCAHPS training and 
materials and the cost of reporting HCAHPS results to CMS is minimal.
    The benefits of public reporting for hospitals are great. There are 
multiple reports of hospitals being motivated by these data and using 
them for improvement. Not only is there more consistent evidence 
regarding hospital impact, but there are also several well-designed 
studies that have found at least some impact on hospital clinical 
performance (Abt report).
    HCAHPS provides many benefits to hospitals and also to society at-
large. The HCAHPS initiative has taken substantial steps to assure that 
the survey will be credible, useful, and practical. First, the survey 
is designed to produce comparable data on the patient's perspective of 
care that allow objective and meaningful comparisons between hospitals 
on domains that are important to consumers. Second, public reporting of 
the survey results is designed to create incentives for hospitals to 
improve their quality of care. Third, public reporting will serve to 
enhance public accountability in health care by increasing the 
transparency of the quality of hospital care provided in return for the 
public investment. For the public at-large, there is the potential 
benefit of improved health through improvements in hospital care.
    The intent of HCAHPS is to provide one standardized instrument and 
accompanying data collection methodology that is in the public domain 
for measuring patients' perspectives of hospital care. While many 
hospitals currently collect information on patients' satisfaction with 
care, there is no one national standard for collecting or publicly 
reporting this information that would enable valid comparisons to be 
made across all hospitals. In order to make ``apples to apples'' 
comparisons to support consumer choice, it is necessary to introduce a 
standard measurement approach. HCAHPS can be viewed as a core set of 
questions that can be combined with a broader, customized set of 
hospital-specific items. HCAHPS is meant to complement the data 
hospitals currently collect to support improvements in internal 
customer services and quality related activities.
     SCIP
    While there are no capital or operational/maintenance costs 
associated with the implementation of SCIP, our pilot study concluded 
that there will be costs associated with the collection of the data. 
The data collection costs have been calculated as follows: SCIP 
collection as additional measures has been calculated to be $75.00 and 
$100.00 per additional hour of data abstraction (approximately $16,000 
per hospital). Depending on the proportion of hospitals that already 
collect these measures, it is estimated that the costs of collecting 
the additional measures is approximately $58.7 million per year. For a 
detailed discussion of the data collection burden (burden hours) 
associated with these costs, please refer to the information collection 
section of the preamble.
     Mortality
    The 30-day mortality measures for AMI and HF are each individually 
calculated solely on administrative data already submitted to CMS for 
other purposes, such as claims submitted for payment by the hospitals. 
As no new or additional data will be required from hospitals to 
calculate the rates for these measures, we believe that there will be 
no measurable impact on the hospitals as a result of the inclusion of 
these measures in the RHQDAPU set.
1. Alternatives Considered
    The HCAHPS survey and the SCIP and mortality measures are a subset 
of CMS's larger Quality Initiative for both the Medicare and Medicaid 
programs. The Hospital Quality Initiative was established nationally in 
November 2002 for nursing homes, and was expanded in 2003 to the 
nation's home health care agencies and hospitals. The Hospital Quality 
Initiative supports significant improvement in the quality of hospital 
care that is integral to both the Medicare and Medicaid programs. This 
initiative aims to improve hospitals' quality of care by distributing 
objective and easy to understand data on hospital performance. The 
public availability of this information will encourage consumers and 
their physicians to discuss and make better informed decisions on how 
to get the best hospital care, create incentives for hospitals to 
improve care, and support public accountability. In all, improved care 
equates to the improvement of health for Medicare and Medicaid 
beneficiaries.
    HCAHPS, SCIP and Mortality measures parallel the trend in both the 
federal and many state governments to make hospital performance 
information (generally clinical processes or outcomes of care) publicly 
available. The goals of HCAHPS are to: (1) Produce comparable data on 
the patient's perspective of care to allow objective and meaningful 
comparisons between hospitals on domains that are important to consumer 
decision-making; (2) to have these data publicly reported to create 
incentives for hospitals to improve their quality of care; and (3) to 
enhance public accountability by providers by increasing the 
transparency of the quality of hospital care provided in return for the 
public investment. HCAHPS, SCIP and Mortality measures fit into a 
larger context of performance reporting developed by the Strategic 
Framework Board of the National Quality Forum. This is based on the 
assumption that consumers take value (both cost and quality) into 
account in any major purchasing decision. Public reporting of both the 
clinical measures and HCAHPS is vital to the value-based healthcare 
purchasing approach. Patient

[[Page 68225]]

perspectives of care encompasses an important CMS priority, as 
indicated by the Agency's support for programs related to the Institute 
of Medicine's (IOM) call for public reporting, the Hospital Quality 
Initiative (HQI) and the Hospital Quality Alliance (HQA), a public-
private measurement and reporting collaborative.
    The HCAHPS survey has been endorsed by the National Quality Forum. 
Implementing this survey fulfills the requirements of sections 1886 
(b)(3)(B)(viii)(III) and (IV) of the Act that require CMS to expand the 
starter set of 10 quality measures used since FY 2005. In expanding 
these measures, we must begin to adopt the baseline set of performance 
measures as set forth in a 2005 report issued by the Institute of 
Medicine (IOM) of the National Academy of Sciences under section 238(b) 
of Public Law 108-173, effective for payments beginning with FY 2007. 
The IOM measures include the Hospital Quality Alliance (HQA) measures, 
the HCAHPS patient perspective survey, and three structural measures.
    No alternatives were discussed for the SCIP and mortality measures.
2. Estimated Effects of This Final Rule With Comment Period
a. Effects on Hospitals
    Hospitals will benefit from the information that the HCAHPS survey 
and the SCIP and Mortality measures data collection will provide. 
Hospitals are an essential part of the National Quality Forum's 
Strategic Framework Board. We have made provisions that reduce the 
burden of the HCAHPS initiative, especially for small/rural hospitals. 
The public reporting of HCAHPS results and additional quality measures 
may stimulate improvements in hospital quality of care in several ways. 
Hospitals can use the publicly reported data to benchmark their 
performance with other institutions. Consumers/patients would 
potentially seek care in hospitals that are publicly reported to 
perform well.
    CMS does not plan to make major revisions to the HCAHPS survey 
itself or to its implementation procedures soon after HCAHPS national 
implementation. With the core set of HCAHPS measures, hospitals will 
have the beginnings of a benchmark for trending of their hospital 
results over time.
    To promote its wide and rapid adoption, HCAHPS has been carefully 
designed to fit within the framework of patient satisfaction surveying 
that hospitals currently employ. Still, CMS fully understands that 
participation in the HCAHPS initiative will require some effort and 
expense on the part of hospitals that volunteer to take part.
b. Effects on Other Providers
    Physicians will benefit by learning what surveyed consumers/
patients answered about their quality of care during their hospital 
stays, as well as become informed about surgical care improvement and 
mortality rates. Studies indicate that providers are potentially 
affected by public reporting. They may be motivated to improve the 
quality of care they deliver with the availability of performance 
information. Primary care physicians are also users of this information 
during the referral process of patients to hospitals. Studies indicate 
that the public reporting of hospital quality indicators may spur 
internal hospital quality improvement and lead to changes in physician 
behavior within the hospital environment.
c. Effects on the Medicare and Medicaid Programs
    Some potential benefits of publicly reporting quality information 
has been described in the literature as pertaining to consumers, 
providers and purchasers. Consumers (beneficiaries) could incorporate 
the quality information into their decision-making about hospital 
choices, and benefit from better care resulting from the additional 
measures as well as the questions asked by HCAHPS, such as questions 
about communication with providers (fewer medical errors due to patient 
feedback about medication effect) and discharge planning (fewer 
readmissions due to better patient awareness about what to expect when 
discharged) and the reporting of clinical measures.
    Providers could potentially be motivated to improve the quality of 
care they provide for results of more effective and efficient hospital 
operation. Providers could also use the information internally to 
improve communication and improve performance, use the information to 
justify the need to increase staff ratios, use the measures in choices 
about practitioner practice locales, use the information to improve 
their ratings on patient perspectives and potentially compete with one 
another in the area of improving accreditation results, and use the 
information to choose hospitals on the basis of quality of care for 
their patients.
    Purchasers could potentially benefit from this information for 
supporting shorter lengths of stay, availability of benchmarks, and 
availability of information to support purchasing decisions.

F. Executive Order 12866

    In accordance with the provisions of Executive Order 12866, this 
final rule with comment period was reviewed by the OMB.

List of Subjects

42 CFR Part 410

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

42 CFR Part 416

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

42 CFR Part 419

    Hospitals, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 421

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

42 CFR Part 485

    Grant program-health, Health facilities, Medicaid, Medicare, 
Reporting and recordkeeping requirements.

42 CFR Part 488

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


0
For reasons stated in the preamble of this final rule with comment 
period, the Centers for Medicare & Medicaid Services is amending 42 CFR 
Chapter IV as set forth below:

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

0
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).


0
2. Section 410.152 is amended by revising paragraph (i) and removing 
footnote 1 to read as follows:


Sec.  410.152  Amounts of payment.

* * * * *
    (i) Amount of payment: ASC facility services. (1) For ASC facility 
services furnished on or after July 1, 1987 and before January 1, 2008, 
in connection with the surgical procedures specified in part 416 of 
this chapter, Medicare Part B pays 80 percent of a standard overhead 
amount as specified in Sec.  416.120(c) of this chapter, except that,

[[Page 68226]]

for screening flexible sigmoidoscopies and screening colonoscopies, 
Part B coinsurance is 25 percent of the standard overhead amount and 
Medicare Part B pays 75 percent of the standard overhead amount.
    (2) [Reserved]
* * * * *

PART 416--AMBULATORY SURGICAL SERVICES

0
3. The authority citation for Part 416 continues to read as follows:

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


0
4. Section 416.1 is amended by--
0
a. Revising paragraph (a)(2).
0
b. Revising paragraph (a)(3).
0
c. Adding new paragraphs (a)(4) and (a)(5).
    The revisions and additions read as follows:


Sec.  416.1  Basis and scope.

    (a) * * *
    (2) Section 1833(i)(1)(A) of the Act requires the Secretary to 
specify the surgical procedures that can be performed safely on an 
ambulatory basis in an ambulatory surgical center.
    (3) Sections 1833(i)(2)(A) and (D) and 1833(a)(1)(G) of the Act 
specify the amounts to be paid for facility services furnished in 
connection with the specified surgical procedures when they are 
performed in an ASC.
    (4) Section 1833(i)(2)(C) of the Act provides that if the Secretary 
has not updated amounts for ASC facility services furnished during a 
fiscal year through 2005 or a calendar year beginning with 2006, the 
amounts shall be increased by the percentage increase in the Consumer 
Price Index for all urban consumers as estimated by the Secretary for 
the 12-month period ending with the midpoint of the year involved, 
except that, in fiscal year 2005, the last quarter of calendar year 
2005, and each of the calendar years 2006 through 2009, the increase 
shall be zero percent.
    (5) Section 1833(i)(2)(E) of the Act provides that, with respect to 
surgical procedures furnished on or after January 1, 2007, and before 
the effective date of the implementation of a revised payment system, 
the payment amount shall be the lesser of the ASC payment rate 
established under section 1833(i)(2)(A) of the Act or the prospective 
payment rate for hospital outpatient department services established 
under section 1833(t)(3)(D) of the Act. The lesser payment amount shall 
be determined prior to application of any geographic adjustment.
* * * * *

0
5. Section 416.2 is amended by revising the definitions of ``Covered 
surgical procedures'' and ``Facility services'' to read as follows:


Sec.  416.2  Definitions.

* * * * *
    Covered surgical procedures means those surgical procedures that 
meet the criteria specified in Sec.  416.65 and are published in the 
Federal Register.
    Facility services means services that are furnished in connection 
with covered surgical procedures performed in an ASC.

0
6. The heading for Subpart D is revised to read as follows:

Subpart D--Scope of Benefits for Services Furnished Before January 
1, 2008

0
7. Section 416.65 is amended by--
0
a. Revising the introductory text.
0
b. Revising paragraph (a)(4).
    The revisions read as follows:


Sec.  416.65  Covered surgical procedures.

    Effective for services furnished before January 1, 2008, covered 
surgical procedures are those procedures that meet the standards 
described in paragraphs (a) and (b) of this section and are included in 
the list published in accordance with paragraph (c) of this section.
    (a) * * *
    (4) Are not otherwise excluded under Sec.  411.15 of this chapter.
* * * * *

0
8. A new Sec.  416.76 is added to Subpart D to read as follows:


Sec.  416.76  Applicability.

    The provisions of this subpart apply to facility services furnished 
before January 1, 2008.

0
9. The heading for Subpart E is revised to read as follows:

Subpart E--Prospective Payment System for Facility Services 
Furnished Before January 1, 2008


Sec.  416.120  [Amended]

0
10. In paragraph (a) of Sec.  416.120, the cross-reference ``Part 413'' 
is removed and the cross-reference ``Part 419'' added in its place.

0
11. A new Sec.  416.121 is added to read as follows:


Sec.  416.121  Applicability.

    The provisions of this subpart apply to facility services furnished 
before January 1, 2008.

0
12. Section 416.125 is amended by adding a new paragraph (c) to read as 
follows:


Sec.  416.125  ASC facility services payment rate.

* * * * *
    (c) For services furnished on or after January 1, 2007, and before 
the effective date of implementation of a revised payment system, the 
ASC payment rate for a surgical procedure is the lesser of the ASC 
payment rate established under paragraph (a) of this section or the 
prospective payment rate for the procedure established under Sec.  
419.32 of this chapter. The lesser payment amount is determined prior 
to application of any geographic adjustment.


Sec.  416.150  [Removed]

0
13. Section 416.150 is removed.

Subpart F [Redesignated]

0
14. Subpart F is redesignated as Subpart G.

New Subpart F [Added and Reserved]

0
15. A new Subpart F is added and reserved.

0
16. Newly designated Subpart G is revised to read as follows:

Subpart G--Adjustment in Payment Amounts for New Technology 
Intraocular Lenses Furnished by Ambulatory Service Centers

Sec.
416.180 Basis and scope.
416.185 Process for establishing a new class of new technology IOLs.
416.190 Request for review of payment amount.
416.195 Determination of membership in new classes of new technology 
IOLs.
416.200 Payment adjustment.


Sec.  416.180  Basis and scope.

    (a) Basis. This subpart implements section 141 of Public Law 103-
432, which provides for adjustments to payment amounts for new 
technology intraocular lenses (IOLs) furnished at ambulatory surgical 
centers (ASCs).
    (b) Scope. This subpart sets forth--
    (1) The process for interested parties to request that CMS review 
the appropriateness of the ASC facility fee for insertion of an IOL. 
This process includes a review of whether that payment is reasonable 
and related to the cost of acquiring a lens determined by CMS as 
belonging to a class of new technology IOLs;
    (2) Factors that CMS considers for determination of a new class of 
new technology IOLs; and

[[Page 68227]]

    (3) Application of the payment adjustment.


Sec.  416.185  Process for establishing a new class of new technology 
IOLs.

    (a) Announcement of deadline for requests for review. CMS announces 
the deadline for each year's requests for review of a new class of new 
technology IOLs in the final rule updating the ASC payment rates for 
that calendar year.
    (b) Announcement of new classes of new technology IOLs for which 
review requests have been made and solicitation of public comments. CMS 
announces the requests for review received in a calendar year and the 
deadline for public comments regarding the requests in the proposed 
rule updating the ASC payment rates for the following calendar year. 
The deadline for submission of public comments is 30 days following the 
date of the publication of the proposed rule.
    (c) Announcement of determinations regarding requests for review. 
CMS announces its determinations for a calendar year in the final rule 
updating the ASC payment rates for the following calendar year. CMS 
publishes the codes and effective dates allowed for those lenses 
recognized by CMS as belonging to a class of new technology IOLs. New 
classes of new technology IOLs are effective 30 days following the date 
of publication of the final rule.


Sec.  416.190  Request for review of payment amount.

    (a) When requests can be submitted. A request for review of the 
appropriateness of ASC payment for insertion of an IOL that might 
qualify for a payment adjustment as belonging to a new class of new 
technology IOLs must be submitted to CMS in accordance with the annual 
published deadline.
    (b) Who may submit a request. Any individual, partnership, 
corporation, association, society, scientific or academic 
establishment, or professional or trade organization able to furnish 
the information required in paragraph (c) of this section may request 
that CMS review the appropriateness of the payment amount provided 
under section 1833(i)(2)(A)(iii) of the Act with respect to an IOL that 
meets the criteria of a new technology IOL under Sec.  416.195.
    (c) Content of a request. In order to be accepted by CMS for 
review, a request for review of the ASC payment amount for insertion of 
an IOL must include all the information as specified by CMS.
    (d) Confidential information. In order for CMS to invoke the 
protection allowed under Exemption 4 of the Freedom of Information Act 
(5 U.S.C. 552(b)(4)) and, with respect to trade secrets, the Trade 
Secrets Act (18 U.S.C. 1905), the requestor must clearly identify all 
information that is to be characterized as confidential.


Sec.  416.195  Determination of membership in new classes of new 
technology IOLs.

    (a) Factors to be considered. CMS uses the following criteria to 
determine whether an IOL qualifies for a payment adjustment as a member 
of a new class of new technology IOLs when inserted at an ASC:
    (1) The IOL is approved by the FDA.
    (2) Claims of specific clinical benefits and/or lens 
characteristics with established clinical relevance in comparison to 
currently available IOLs are approved by the FDA for use in labeling 
and advertising.
    (3) The IOL is not described by an active or expired class of new 
technology IOLs; that is, it does not share a predominant, class-
defining characteristic associated with improved clinical outcomes with 
members of an active or expired class.
    (4) Evidence demonstrates that use of the IOL results in 
measurable, clinically meaningful, improved outcomes in comparison with 
use of currently available IOLs. Superior outcomes include:
    (i) Reduced risk of intraoperative or postoperative complication or 
trauma;
    (ii) Accelerated postoperative recovery;
    (iii) Reduced induced astigmatism;
    (iv) Improved postoperative visual acuity;
    (v) More stable postoperative vision;
    (vi) Other comparable clinical advantages.
    (b) CMS determination of eligibility for payment adjustment. CMS 
reviews the information submitted with a completed request for review, 
public comments submitted timely, and other pertinent information and 
makes a determination as follows:
    (1) The IOL is eligible for a payment adjustment as a member of a 
new class of new technology IOLs.
    (2) The IOL is a member of an active class of new technology IOLs 
and is eligible for a payment adjustment for the remainder of the 
period established for that class.
    (3) The IOL does not meet the criteria for designation as a new 
technology IOL and a payment adjustment is not appropriate.


Sec.  416.200  Payment adjustment.

    (a) CMS establishes the amount of the payment adjustment for 
classes of new technology IOLs through proposed and final rulemaking in 
connection with ASC facility services.
    (b) CMS adjusts the payment for insertion of an IOL approved as 
belonging to a class of new technology IOLs for the 5-year period of 
time established for that class.
    (c) Upon expiration of the 5-year period of the payment adjustment, 
payment reverts to the standard rate for IOL insertion procedures 
performed in ASCs.
    (d) ASCs that furnish an IOL designated by CMS as belonging to a 
class of new technology IOLs must submit claims using billing codes 
specified by CMS to receive the new technology IOL payment adjustment.

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

0
17. The authority citation for Part 419 continues to read as follows:

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


0
18. Section 419.21 is amended by revising the introductory text of 
paragraph (d) to read as follows:


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

* * * * *
    (d) The following medical and other health services furnished by a 
home health agency (HHA) to patients who are not under an HHA plan or 
treatment or by a hospice program furnishing services to patients 
outside the hospice benefit:
* * * * *

0
19. Section 419.43 is amended by--
0
a. Revising paragraph (f).
0
b. Revising paragraph (g)(1)(i).
0
c. Adding a new paragraph (h).
    The revision and addition read as follows:


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

* * * * *
    (f) Excluded services and groups. Drugs and biologicals that are 
paid under a separate APC are excluded from qualification for outlier 
payments.
    (g) * * *
    (1) * * *
    (i) Is a sole community hospital under Sec.  412.92 of this chapter 
or is an essential access community hospital under Sec.  412.109 of 
this chapter; and
* * * * *
    (h) Applicable adjustments to conversion factor for CY 2009 and for 
subsequent calendar years--(1) General

[[Page 68228]]

rule. For CY 2009 and for subsequent calendar years, the applicable 
adjustment to the conversion factor specified in Sec.  419.32(b)(1)(iv) 
is reduced by 2.0 percentage points for any hospital that fails to meet 
the standards for reporting of hospital outpatient quality measures as 
established by the Secretary for the corresponding calendar year.
    (2) Limitation. Any reduction to a hospital's adjustment to its 
conversion factor specified in Sec.  419.32(b)(1)(iv) which occurs as a 
result of paragraph (h)(1) of this section will apply only to the 
calendar year involved and will not be taken into account in computing 
that hospital's applicable adjustment for a subsequent calendar year.
    (3) Budget neutrality. For CY 2009 and for each subsequent calendar 
year, CMS makes an adjustment to the conversion factor, so that 
estimated aggregate payments under the OPPS for such calendar year are 
not affected by any reductions to hospital adjustments which occur as a 
result of paragraph (h)(1) of this section,

0
20. A new Sec.  419.45 is added to Subpart D to read as follows:


Sec.  419.45  Payment and copayment reduction for devices replaced 
without cost or full credit is received.

    (a) General rule. CMS reduces the amount of payment for an 
implanted device made under the hospital outpatient prospective payment 
system in accordance with Sec.  419.66 for which CMS determines that a 
significant portion of the payment is attributable to the cost of an 
implanted device, when one of the following situations occur:
    (1) The device is replaced without cost to the provider or the 
beneficiary; or
    (2) The provider receives full credit for the cost of a replaced 
device.
    (b) Amount of reduction to the APC payment. The amount of the 
reduction to the APC payment made under paragraph (a) of this section 
is calculated in the same manner as the offset amount that would be 
applied if the device implanted in a procedure assigned to the APC had 
transitional pass-through status under Sec.  419.66.
    (c) Amount of beneficiary copayment. The beneficiary copayment is 
calculated based on the APC payment after application of the reduction 
under paragraph (b) of this section.

0
21. Section 419.70 is amended by--
0
a. Revising paragraph (d)(1).
0
b. Redesignating paragraphs (d)(2) and (d)(3) as paragraphs (d)(3) and 
(d)(4), respectively.
0
c. Adding a new paragraph (d)(2).
    The revisions and addition read as follows:


Sec.  419.70  Transitional adjustment to limit decline in payments.

* * * * *
    (d) Hold harmless provisions--(1) Temporary treatment for small 
rural hospitals before January 1, 2006. For covered hospital outpatient 
services furnished in a calendar year before January 1, 2006, for which 
the prospective payment system amount is less than the pre-BBA amount, 
the amount of payment under this part is increased by the amount of 
that difference if the hospital--
    (i) Is located in a rural area as defined in Sec.  412.63(b) of 
this chapter or is treated as being located in a rural area under 
section 1886(d)(8)(E) of the Act; and
    (ii) Has 100 or fewer beds as defined in Sec.  412.105(b) of this 
chapter.
    (2) Temporary treatment for small rural hospitals on or after 
January 1, 2006. For covered hospital outpatient services furnished in 
a calendar year from January 1, 2006, through December 31, 2008, for 
which the prospective payment system amount is less than the pre-BBA 
amount, the amount of payment under this paragraph is increased by 95 
percent of that difference for services furnished during 2006, 90 
percent of that difference for services furnished during 2007, and 85 
percent of that difference for services furnished during 2008 if the 
hospital--
    (i) Is located in a rural area as defined in Sec.  412.63(b) of 
this chapter or is treated as being located in a rural area under 
section 1886(d)(8)(E) of the Act;
    (ii) Has 100 or fewer beds as defined in Sec.  412.105(b) of this 
chapter;
    (iii) Is not a sole community hospital as defined in Sec.  412.92 
of this chapter; and
    (iv) Is not an essential access community hospital under Sec.  
412.109 of this chapter.
* * * * *

PART 421--MEDICARE CONTRACTING

0
22. The heading of Part 421 is revised to read as set out above.
0
23. The authority citation for Part 421 continues to read as follows:

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


0
24. Section 421.3 is revised to read as follows:


Sec.  421.3  Definitions.

    As used in this part--
    Intermediary means an entity that has a contract with CMS (under 
statutory provisions in effect prior to October 1, 2005) to determine 
and make Medicare payments for Part A or Part B benefits payable on a 
cost basis (or under the prospective payment system for hospitals) and 
to perform other related functions. For purposes of applying the 
performance criteria in Sec.  421.120 and the performance standards in 
Sec.  421.122 and any adverse action resulting from that application, 
the term ``intermediary'' also means a Blue Cross plan that has entered 
into a subcontract approved by CMS with the Blue Cross and Blue Shield 
Association to perform intermediary functions.

0
25. Section 421.100 is amended by revising paragraph (i) to read as 
follows:


Sec.  421.100  Intermediary functions.

* * * * *
    (i) Dual intermediary responsibilities. Regarding the 
responsibility for service to provider-based HHAs and provider-based 
hospices, where the HHA or the hospice and its parent provider will be 
served by different intermediaries, the designated regional 
intermediary will process bills, make coverage determinations, and make 
payments to the HHAs and the hospices. The intermediary serving the 
parent provider will perform all fiscal functions, including audits and 
settlement of the Medicare cost reports and the HHA and hospice 
supplement worksheets.

0
26. Section 421.103 is revised to read as follows:


Sec.  421.103  Payment to providers.

    Providers are assigned to intermediaries in accordance with Sec.  
421.104. As the Medicare Administrative Contractors (MACs) are 
implemented, providers are reassigned from intermediaries to MACs in 
accordance with Sec.  412.404 of this chapter.

0
27. Section 421.104 is revised to read as follows:


Sec.  421.104  Assignment of providers of services to intermediaries 
during transition to Medicare Administrative Contractors (MACs).

    (a) Beginning October 1, 2005, CMS assigns providers of services 
and other entities that may bill Part A benefits to intermediaries in a 
manner that will best support the transition to Medicare Administrative 
Contractors (MACs) under section 1874A of the Act in accordance with 
Subpart E of this part.
    (b) These providers of services and other entities must continue to 
bill the intermediary that they were billing prior to October 1, 2005, 
until one of the following events occurs:
    (1) The intermediary's agreement with CMS ends, and the provider or 
entity is

[[Page 68229]]

directed by CMS to bill another CMS contractor.
    (2) The provider or entity is assigned to a MAC that has begun to 
administer claims within the geographic locale of the provider or 
entity.
    (3) CMS directs the provider or entity to begin billing another CMS 
contractor in order to support the implementation of MACs under section 
1874A of the Act and Subpart E of this part.
    (c) New providers of services and new entities will be assigned to 
the intermediary serving their geographic locale if no MAC has begun to 
administer Medicare claims in the locale. These providers or entities 
must continue to bill the intermediary until one of the events in 
paragraph (b) of this section occurs.
    (d) Providers or entities will only be granted exceptions to the 
provisions of paragraphs (b) or (c) of this section if CMS deems the 
exception to be in the compelling interest of the Medicare program.
    (e) CMS will notify the provider or entity, the outgoing 
intermediary, and the newly assigned intermediary of assignment or 
reassignment decisions.


Sec.  421.105  [Removed]

0
28. Section 421.105 is removed.


Sec.  421.106  [Removed]

0
29. Section 421.106 is removed.
0
30. Section 421.112 is amended by--
0
a. Revising paragraph (a).
0
b. Revising paragraph (b).
    The revisions read as follows:


Sec.  421.112  Considerations relating to the effective and efficient 
administration of the program.

    (a) In order to accomplish the most effective and efficient 
administration of the Medicare program, the Secretary may make 
determinations with respect to the termination of an intermediary 
agreement, and CMS may make determinations with respect to renewal of 
an intermediary agreement under Sec.  421.110.
    (b) When taking the actions specified in paragraph (a) of this 
section, the Secretary or CMS will consider the performance of the 
individual intermediary in its Medicare operations using the factors 
contained in the performance criteria specified in Sec.  421.120 and 
the performance standards specified in Sec.  421.122.
* * * * *

0
31. Section 421.114 is revised to read as follows:


Sec.  421.114  Assignment and reassignment of providers by CMS.

    CMS may assign or reassign any provider to any intermediary if it 
determines that the assignment or reassignment will be in the best 
interests of the Medicare program.


Sec.  421.116  [Removed]

0
32. Section 421.116 is removed.


Sec.  421.117  [Removed]

0
33. Section 421.117 is removed.


Sec.  421.118  [Removed]

0
34. Section 421.118 is removed.

Subpart D [Added and Reserved]

0
35. Subpart D is added to Part 421 and reserved.
0
36. A new Subpart E is added to Part 421 to read as follows:

Subpart E--Medicare Administrative Contractors (MACs)

Sec.
421.400 Statutory basis and scope.
421.401 Definitions.
421.404 Assignment of providers and suppliers to MACs.


Sec.  421.400  Statutory basis and scope.

    (a) Statutory basis. This subpart implements section 1874A of the 
Act, which provides for the transition of the claims processing 
functions and operations for both Medicare Part A and Part B 
intermediaries and carriers to Medicare Administrative Contractors 
(MACs). The transition will occur between October 1, 2005, and October 
1, 2011. MACs will be fully operational in distinct, nonoverlapping 
geographic jurisdictions by October 1, 2011.
    (b) Scope. This subpart specifies the requirements under which 
providers and suppliers will be assigned to MACs.


Sec.  421.401  Definitions.

    For purposes of this subpart--
    Appropriate MAC means a MAC that has a contract under section 1874A 
of the Act to perform a particular Medicare administrative function in 
relation to:
    (1) A particular individual entitled to benefits under Part A or 
enrolled under Part B, or both;
    (2) A specific provider of services or supplier; or
    (3) A class of providers of services or suppliers.
    Medicare Administrative Contractor (MAC) means an agency, 
organization, or other person with a contract under section 1874A of 
the Act.


Sec.  421.404  Assignment of providers and suppliers to MACs.

    (a) Definitions. As used in this section--
    Chain provider means a group of two or more providers under common 
ownership or control.
    Common control exists when an individual, a group of individuals, 
or an organization has the power, directly or indirectly, to 
significantly influence or direct the actions or policies of the group 
of suppliers or eligible providers.
    Common ownership exists when an individual, a group of individuals, 
or an organization possesses significant equity in the group of 
suppliers or eligible providers.
    Durable medical equipment, prosthetics, orthotics, and supplies 
(DMEPOS) means the types of services specified in Sec.  421.210(b).
    Eligible provider means a hospital, skilled nursing facility, or 
critical access hospital that meets the definition of a provider under 
Sec.  400.202 of this chapter.
    Home office means the entity that provides centralized management 
and administrative services to the individual providers or suppliers 
under common ownership and common control, such as centralized 
accounting, purchasing, personnel services, management direction and 
control, and other similar services.
    Ineligible provider means a provider under Sec.  400.202 of this 
chapter that is not an eligible provider.
    Medicare benefit category means a category of covered benefits 
under Part A or Part B of the Medicare program (for example, inpatient 
hospital services, post-hospital extended care services, and 
physicians' services).
    Provider has the same meaning as specified under Sec.  400.202 of 
this chapter.
    Qualified chain provider means a chain provider comprised of--
    (1) 10 or more eligible providers collectively totaling 500 or more 
certified beds; or
    (2) 5 or more eligible providers collectively totaling 300 or more 
certified beds, with eligible providers in 3 or more contiguous States.
    Supplier has the same meaning as specified in Sec.  400.202 of this 
chapter.
    (b) Assignment of providers to MACs. (1) Providers enroll with and 
receive Medicare payment and other Medicare services from the MAC 
contracted by CMS to administer claims for the Medicare benefit 
category applicable to the provider's covered services for the 
geographic locale in which the provider is physically located.
    (2) Qualified chain providers may request and receive an exception 
from the requirement of paragraph (b)(1) of this section from CMS. Upon 
CMS' approval, a qualified chain provider may enroll with and bill on 
behalf of the eligible providers under its common ownership or common 
control to the

[[Page 68230]]

MAC contracted by CMS to administer claims for the Medicare benefit 
category applicable to the eligible providers' covered services for the 
geographic locale in which the qualified chain provider's home office 
is physically located.
    (3) As MAC contractors become available, qualified chain providers, 
granted approval by CMS to enroll with and bill a single intermediary 
on behalf of their eligible member providers prior to October 1, 2005, 
will be assigned at an appropriate time to the MAC contracted by CMS to 
administer claims for the applicable Medicare benefit category for the 
geographic locale in which the chain provider's home office is 
physically located. The qualified chain provider will not need to 
request an exception to the requirement of paragraph (b)(1) of this 
section in order for this assignment to take effect.
    (4) CMS may grant an exception to the requirement of paragraph 
(b)(1) of this section to eligible providers that are not under the 
common ownership or common control of a qualified chain provider, as 
well as ineligible providers, only if CMS finds the exception will 
support the implementation of MACs or will serve some other compelling 
interest of the Medicare program.
    (c) Assignment of suppliers to MACs. (1) Suppliers, including 
physicians and other practitioners, but excluding suppliers of DMEPOS, 
enroll with and receive Medicare payment and other Medicare services 
from the MAC contracted by CMS to administer claims for the Medicare 
benefit category applicable to the supplier's covered services for the 
geographic locale in which the supplier furnished such services.
    (2) Suppliers of DMEPOS receive Medicare payment and other Medicare 
services from the MAC assigned to administer claims for DMEPOS for the 
regional area in which the beneficiary receiving the DMEPOS resides. 
The terms of Sec. Sec.  421.210 and 421.212 continue to apply to 
suppliers of DMEPOS.
    (3) CMS may allow a group of ESRD suppliers under common ownership 
and common control to enroll with the MAC contracted by CMS to 
administer ESRD claims for the geographic locale in which the group's 
home office is located only if--
    (i) The group of ESRD suppliers requests such privileges; and
    (ii) CMS finds the exception will support the implementation of 
MACs or will serve some other compelling interest of the Medicare 
program.

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

0
37. The authority citation for Part 485 continues to read as follows:

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


0
38. Section 485.618 is amended by--
0
a. Revising paragraph (d)(1) introductory text.
0
b. Redesignating paragraphs (d)(2) and (d)(3) as paragraphs (d)(3) and 
(d)(4), respectively.
0
c. Adding a new paragraph (d)(2).
0
d. In redesignated paragraph (d)(3)(iv), removing the cross-reference 
``paragraph (d)(2)(iii)'' and adding the cross-reference ``paragraph 
(d)(3)(iii)'' in its place.
0
e. In redesignated paragraph (d)(4), removing the cross-reference 
``paragraph (d)(2)(iii)'' and adding the cross-reference ``paragraph 
(d)(3)(iii)'' in its place.
    The revisions and additions read as follows:


Sec.  485.618  Condition of participation: Emergency services.

* * * * *
    (d) Standard: Personnel. (1) Except as specified in paragraph 
(d)(3) of this section, there must be a doctor of medicine or 
osteopathy, a physician assistant, a nurse practitioner, or a clinical 
nurse specialist, 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:
* * * * *
    (2) A registered nurse with training and experience in emergency 
care can be utilized to conduct specific medical screening examinations 
only if--
    (i) The registered nurse is on site and immediately available at 
the CAH when a patient requests medical care; and
    (ii) The nature of the patient's request for medical care is within 
the scope of practice of a registered nurse and consistent with 
applicable State laws and the CAH's bylaws or rules and regulations.
* * * * *

PART 488--SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES

0
39. The authority citation for Part 488 continues to read as follows:

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


0
41. In Sec.  488.1, the definition of ``supplier'' is revised to read 
as follows:


Sec.  488.1  Definitions.

* * * * *
    Supplier means any of the following: Independent laboratory; 
portable X-ray services; physical therapist in independent practice; 
ESRD facility; rural health clinic; Federally qualified health center; 
chiropractor; or ambulatory surgical center.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: October 27, 2006.
Leslie Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: October 31, 2006.
Michael O. Leavitt,
Secretary.

[[Page 68231]]



    Addendum A.--OPPS List of Ambulatory Payment Classifications (APCs) With Status Indicators (SI), Relative
                                Weights, and Copayment Amounts Calendar Year 2007
----------------------------------------------------------------------------------------------------------------
                                                                                          National     Minimum
        APC                  Group title              SI        Relative     Payment     Unadjusted   Unadjusted
                                                                 Weight        Rate      Copayment    Copayment
----------------------------------------------------------------------------------------------------------------
0001...............  Level I Photochemotherapy.  S                 0.4914        30.21         7.00         6.04
0002...............  Level I Fine Needle Biopsy/ T                 1.0995        67.58  ...........        13.52
                      Aspiration.
0003...............  Bone Marrow Biopsy/         T                 2.4011       147.59  ...........        29.52
                      Aspiration.
0004...............  Level I Needle Biopsy/      T                 2.0687       127.16  ...........        25.43
                      Aspiration Except Bone
                      Marrow.
0005...............  Level II Needle Biopsy/     T                 3.9045       240.00        71.59        48.00
                      Aspiration Except Bone
                      Marrow.
0006...............  Level I Incision &          T                 1.4392        88.46  ...........        17.69
                      Drainage.
0007...............  Level II Incision &         T                11.1535       685.58  ...........       137.12
                      Drainage.
0008...............  Level III Incision and      T                17.5086     1,076.22  ...........       215.24
                      Drainage.
0009...............  Nail Procedures...........  T                 0.7744        47.60  ...........         9.52
0010...............  Level I Destruction of      T                 0.4760        29.26         8.02         5.85
                      Lesion.
0011...............  Level II Destruction of     T                 2.5665       157.76  ...........        31.55
                      Lesion.
0012...............  Level I Debridement &       T                 0.8432        51.83        11.18        10.37
                      Destruction.
0013...............  Level II Debridement &      T                 1.0918        67.11  ...........        13.42
                      Destruction.
0015...............  Level III Debridement &     T                 1.6241        99.83        20.13        19.97
                      Destruction.
0016...............  Level IV Debridement &      T                 2.6749       164.42  ...........        32.88
                      Destruction.
0017...............  Level VI Debridement &      T                17.4423     1,072.14       227.84       214.43
                      Destruction.
0018...............  Biopsy of Skin/Puncture of  T                 1.0259        63.06        15.44        12.61
                      Lesion.
0019...............  Level I Excision/ Biopsy..  T                 4.0919       251.52        71.87        50.30
0020...............  Level II Excision/ Biopsy.  T                 6.8083       418.49       107.67        83.70
0021...............  Level III Excision/ Biopsy  T                15.1024       928.31       219.48       185.66
0022...............  Level IV Excision/ Biopsy.  T                20.0656     1,233.39       354.45       246.68
0023...............  Exploration Penetrating     T                 4.2212       259.47  ...........        51.89
                      Wound.
0024...............  Level I Skin Repair.......  T                 1.4843        91.24        29.88        18.25
0025...............  Level II Skin Repair......  T                 5.2594       323.28       101.85        64.66
0027...............  Level IV Skin Repair......  T                21.4302     1,317.27       329.72       263.45
0028...............  Level I Breast Surgery....  T                19.2788     1,185.03       303.74       237.01
0029...............  Level II Breast Surgery...  T                28.0166     1,722.12       581.52       344.42
0030...............  Level III Breast Surgery..  T                37.8692     2,327.74       747.07       465.55
0031...............  Smoking Cessation Services  X                 0.1766        10.86  ...........         2.17
0033...............  Partial Hospitalization...  P                 3.8188       234.73  ...........        46.95
0035...............  Arterial/Venous Puncture..  T                 0.1999        12.29  ...........         2.46
0036...............  Level II Fine Needle        T                 2.0738       127.47  ...........        25.49
                      Biopsy/Aspiration.
0037...............  Level IV Needle Biopsy/     T                10.2655       631.00       228.76       126.20
                      Aspiration Except Bone
                      Marrow.
0038...............  Spontaneous MEG...........  S                53.5161     3,289.53  ...........       657.91
0039...............  Level I Implantation of     S               187.3821    11,518.00  ...........     2,303.60
                      Neurostimulator.
0040...............  Percutaneous Implantation   S                56.5705     3,477.28  ...........       695.46
                      of Neurostimulator
                      Electrodes, Excluding
                      Cranial Nerve.
0041...............  Level I Arthroscopy.......  T                28.6245     1,759.49  ...........       351.90
0042...............  Level II Arthroscopy......  T                45.5027     2,796.96       804.74       559.39
0043...............  Closed Treatment Fracture   T                 1.6857       103.62  ...........        20.72
                      Finger/Toe/Trunk.
0045...............  Bone/Joint Manipulation     T                14.5947       897.11       268.47       179.42
                      Under Anesthesia.
0047...............  Arthroplasty without        T                33.4505     2,056.14       537.03       411.23
                      Prosthesis.
0048...............  Level I Arthroplasty with   T                47.4378     2,915.91  ...........       583.18
                      Prosthesis.
0049...............  Level I Musculoskeletal     T                20.8706     1,282.87  ...........       256.57
                      Procedures Except Hand
                      and Foot.
0050...............  Level II Musculoskeletal    T                25.1296     1,544.67  ...........       308.93
                      Procedures Except Hand
                      and Foot.
0051...............  Level III Musculoskeletal   T                41.0893     2,525.68  ...........       505.14
                      Procedures Except Hand
                      and Foot.
0052...............  Level IV Musculoskeletal    T                66.5800     4,092.54  ...........       818.51
                      Procedures Except Hand
                      and Foot.
0053...............  Level I Hand                T                16.1540       992.95       253.49       198.59
                      Musculoskeletal
                      Procedures.
0054...............  Level II Hand               T                25.8758     1,590.53  ...........       318.11
                      Musculoskeletal
                      Procedures.
0055...............  Level I Foot                T                20.4263     1,255.56       355.34       251.11
                      Musculoskeletal
                      Procedures.
0056...............  Level II Foot               T                40.8559     2,511.33  ...........       502.27
                      Musculoskeletal
                      Procedures.
0057...............  Bunion Procedures.........  T                28.2349     1,735.54       475.91       347.11
0058...............  Level I Strapping and Cast  S                 1.0607        65.20  ...........        13.04
                      Application.
0060...............  Manipulation Therapy......  S                 0.4657        28.63  ...........         5.73
0061...............  Laminectomy or Incision     S                84.1967     5,175.40  ...........     1,035.08
                      for Implantation of
                      Neurostimulator
                      Electrodes, Excluding
                      Cranial Nerve.
0062...............  Level I Treatment Fracture/ T                25.5264     1,569.06       372.87       313.81
                      Dislocation.
0063...............  Level II Treatment          T                37.5382     2,307.40       548.33       461.48
                      Fracture/Dislocation.
0064...............  Level III Treatment         T                57.2172     3,517.03       835.79       703.41
                      Fracture/Dislocation.
0065...............  Level I Stereotactic        S                20.3224     1,249.18  ...........       249.84
                      Radiosurgery.
0066...............  Level II Stereotactic       S                43.0297     2,644.95  ...........       528.99
                      Radiosurgery.
0067...............  Level III Stereotactic      S                63.3759     3,895.59  ...........       779.12
                      Radiosurgery.
0068...............  CPAP Initiation...........  S                 1.5353        94.37        29.48        18.87
0069...............  Thoracoscopy..............  T                31.9442     1,963.55       591.64       392.71
0070...............  Thoracentesis/Lavage        T                 3.6244       222.78  ...........        44.56
                      Procedures.
0071...............  Level I Endoscopy Upper     T                 0.7698        47.32        11.20         9.46
                      Airway.
0072...............  Level II Endoscopy Upper    T                 1.4054        86.39        21.27        17.28
                      Airway.
0073...............  Level III Endoscopy Upper   T                 3.8463       236.42        69.15        47.28
                      Airway.
0074...............  Level IV Endoscopy Upper    T                14.7928       909.28       292.25       181.86
                      Airway.

[[Page 68232]]

 
0075...............  Level V Endoscopy Upper     T                21.9512     1,349.30       445.92       269.86
                      Airway.
0076...............  Level I Endoscopy Lower     T                 9.5228       585.35       189.82       117.07
                      Airway.
0077...............  Level I Pulmonary           S                 0.3527        21.68         7.74         4.34
                      Treatment.
0078...............  Level II Pulmonary          S                 1.1206        68.88        14.55        13.78
                      Treatment.
0079...............  Ventilation Initiation and  S                 2.6116       160.53  ...........        32.11
                      Management.
0080...............  Diagnostic Cardiac          T                37.0615     2,278.10       838.92       455.62
                      Catheterization.
0081...............  Non-Coronary Angioplasty    T                42.9360     2,639.19  ...........       527.84
                      or Atherectomy.
0082...............  Coronary Atherectomy......  T                72.1982     4,437.88       954.62       887.58
0083...............  Coronary Angioplasty and    T                58.7904     3,613.73  ...........       722.75
                      Percutaneous
                      Valvuloplasty.
0084...............  Level I Electrophysiologic  S                 9.8924       608.07  ...........       121.61
                      Evaluation.
0085...............  Level II                    T                34.2808     2,107.17       426.25       421.43
                      Electrophysiologic
                      Evaluation.
0086...............  Ablate Heart Dysrhythm      T                47.4931     2,919.31       812.36       583.86
                      Focus.
0087...............  Cardiac Electrophysiologic  T                32.8988     2,022.22  ...........       404.44
                      Recording/Mapping.
0088...............  Thrombectomy..............  T                37.7391     2,319.75       655.22       463.95
0089...............  Insertion/Replacement of    T               123.6693     7,601.70     1,682.28     1,520.34
                      Permanent Pacemaker and
                      Electrodes.
0090...............  Insertion/Replacement of    T                98.3023     6,042.45     1,612.80     1,208.49
                      Pacemaker Pulse Generator.
0091...............  Level II Vascular Ligation  T                34.7288     2,134.71  ...........       426.94
0092...............  Level I Vascular Ligation.  T                24.8809     1,529.38       309.87       305.88
0093...............  Vascular Reconstruction/    T                22.8653     1,405.48  ...........       281.10
                      Fistula Repair without
                      Device.
0094...............  Level I Resuscitation and   S                 2.4233       148.96        46.29        29.79
                      Cardioversion.
0095...............  Cardiac Rehabilitation....  S                 0.5748        35.33        13.86         7.07
0096...............  Non-Invasive Vascular       S                 1.5303        94.06        37.62        18.81
                      Studies.
0097...............  Cardiac and Ambulatory      X                 1.0225        62.85        23.79        12.57
                      Blood Pressure Monitoring.
0098...............  Injection of Sclerosing     T                 1.0798        66.37  ...........        13.27
                      Solution.
0099...............  Electrocardiograms........  S                 0.3789        23.29  ...........         4.66
0100...............  Cardiac Stress Tests......  X                 2.5336       155.74        41.44        31.15
0101...............  Tilt Table Evaluation.....  S                 4.2769       262.89       100.24        52.58
0103...............  Miscellaneous Vascular      T                16.2375       998.09       223.63       199.62
                      Procedures.
0104...............  Transcatheter Placement of  T                87.7183     5,391.87  ...........     1,078.37
                      Intracoronary Stents.
0105...............  Repair/Revision/Removal of  T                25.6142     1,574.45       370.40       314.89
                      Pacemakers, AICDs, or
                      Vascular Devices.
0106...............  Insertion/Replacement of    T                58.8594     3,617.97  ...........       723.59
                      Pacemaker Leads and/or
                      Electrodes.
0107...............  Insertion of Cardioverter-  T               304.4894    18,716.35  ...........     3,743.27
                      Defibrillator.
0108...............  Insertion/Replacement/      T               379.7339    23,341.48  ...........     4,668.30
                      Repair of Cardioverter-
                      Defibrillator Leads.
0109...............  Removal of Implanted        T                10.9918       675.64  ...........       135.13
                      Devices.
0110...............  Transfusion...............  S                 3.4584       212.58  ...........        42.52
0111...............  Blood Product Exchange....  S                11.7134       720.00       198.40       144.00
0112...............  Apheresis, Photopheresis,   S                30.2231     1,857.75       433.29       371.55
                      and Plasmapheresis.
0113...............  Excision Lymphatic System.  T                21.2621     1,306.94  ...........       261.39
0114...............  Thyroid/Lymphadenectomy     T                37.7224     2,318.72       467.95       463.74
                      Procedures.
0115...............  Cannula/Access Device       T                29.2133     1,795.68       374.81       359.14
                      Procedures.
0121...............  Level I Tube changes and    T                 2.3587       144.98        43.80        29.00
                      Repositioning.
0122...............  Level II Tube changes and   T                 7.4800       459.78  ...........        91.96
                      Repositioning.
0123...............  Bone Marrow Harvesting and  S                20.3582     1,251.38  ...........       250.28
                      Bone Marrow/Stem Cell
                      Transplant.
0125...............  Refilling of Infusion Pump  T                 2.2041       135.48  ...........        27.10
0126...............  Level I Urinary and Anal    T                 1.0887        66.92        16.45        13.38
                      Procedures.
0127...............  Level IV Stereotactic       S               138.4486     8,510.16  ...........     1,702.03
                      Radiosurgery.
0130...............  Level I Laparoscopy.......  T                32.1241     1,974.60       659.53       394.92
0131...............  Level II Laparoscopy......  T                43.5488     2,676.86     1,001.89       535.37
0132...............  Level III Laparoscopy.....  T                70.5066     4,333.90     1,239.22       866.78
0140...............  Esophageal Dilation         T                 5.4566       335.41        91.40        67.08
                      without Endoscopy.
0141...............  Level I Upper GI            T                 8.3175       511.26       143.38       102.25
                      Procedures.
0142...............  Small Intestine Endoscopy.  T                 9.4946       583.61       152.78       116.72
0143...............  Lower GI Endoscopy........  T                 8.7686       538.99       186.06       107.80
0146...............  Level I Sigmoidoscopy and   T                 4.8683       299.24        64.40        59.85
                      Anoscopy.
0147...............  Level II Sigmoidoscopy and  T                 8.5477       525.41  ...........       105.08
                      Anoscopy.
0148...............  Level I Anal/Rectal         T                 5.0770       312.07  ...........        62.41
                      Procedures.
0149...............  Level III Anal/Rectal       T                22.2682     1,368.78       293.06       273.76
                      Procedures.
0150...............  Level IV Anal/Rectal        T                29.6189     1,820.61       437.12       364.12
                      Procedures.
0151...............  Endoscopic Retrograde       T                19.8381     1,219.41       245.46       243.88
                      Cholangio-Pancreatography
                      (ERCP).
0152...............  Level I Percutaneous        T                20.2682     1,245.85  ...........       249.17
                      Abdominal and Biliary
                      Procedures.
0153...............  Peritoneal and Abdominal    T                22.0832     1,357.41       397.95       271.48
                      Procedures.
0154...............  Hernia/Hydrocele            T                29.2182     1,795.98       464.85       359.20
                      Procedures.
0155...............  Level II Anal/Rectal        T                12.7389       783.03  ...........       156.61
                      Procedures.
0156...............  Level III Urinary and Anal  T                 3.4079       209.48  ...........        41.90
                      Procedures.
0157...............  Colorectal Cancer           S                 2.1149       130.00  ...........        26.00
                      Screening: Barium Enema.
0158...............  Colorectal Cancer           T                 7.8492       446.00  ...........       111.50
                      Screening: Colonoscopy.

[[Page 68233]]

 
0159...............  Colorectal Cancer           S                 3.6592       224.92  ...........        56.23
                      Screening: Flexible
                      Sigmoidoscopy.
0160...............  Level I Cystourethroscopy   T                 6.4951       399.24       101.58        79.85
                      and other Genitourinary
                      Procedures.
0161...............  Level II Cystourethroscopy  T                19.2251     1,181.73       249.36       236.35
                      and other Genitourinary
                      Procedures.
0162...............  Level III                   T                23.8700     1,467.24  ...........       293.45
                      Cystourethroscopy and
                      other Genitourinary
                      Procedures.
0163...............  Level IV Cystourethroscopy  T                34.9261     2,146.84  ...........       429.37
                      and other Genitourinary
                      Procedures.
0164...............  Level II Urinary and Anal   T                 2.1393       131.50  ...........        26.30
                      Procedures.
0165...............  Level IV Urinary and Anal   T                18.1679     1,116.74  ...........       223.35
                      Procedures.
0166...............  Level I Urethral            T                18.3960     1,130.77  ...........       226.15
                      Procedures.
0168...............  Level II Urethral           T                29.0253     1,784.13       388.16       356.83
                      Procedures.
0169...............  Lithotripsy...............  T                43.5398     2,676.30     1,009.47       535.26
0170...............  Dialysis..................  S                 6.6089       406.24  ...........        81.25
0171...............  Level V Anal/Rectal         T                37.8991     2,329.58       716.76       465.92
                      Procedures.
0180...............  Circumcision..............  T                20.5513     1,263.25       304.87       252.65
0181...............  Penile Procedures.........  T                32.9873     2,027.66       621.82       405.53
0183...............  Testes/Epididymis           T                23.5310     1,446.40  ...........       289.28
                      Procedures.
0184...............  Prostate Biopsy...........  T                 5.6262       345.83        96.27        69.17
0188...............  Level II Female             T                 1.2900        79.29  ...........        15.86
                      Reproductive Proc.
0189...............  Level III Female            T                 2.8966       178.05  ...........        35.61
                      Reproductive Proc.
0190...............  Level I Hysteroscopy......  T                21.3586     1,312.87       424.28       262.57
0191...............  Level I Female              T                 0.1468         9.02         2.55         1.80
                      Reproductive Proc.
0192...............  Level IV Female             T                 6.6592       409.33  ...........        81.87
                      Reproductive Proc.
0193...............  Level V Female              T                14.8489       912.73  ...........       182.55
                      Reproductive Proc.
0194...............  Level VIII Female           T                20.5081     1,260.59       397.84       252.12
                      Reproductive Proc.
0195...............  Level IX Female             T                28.5095     1,752.42       483.80       350.48
                      Reproductive Proc.
0196...............  Dilation and Curettage....  T                17.7499     1,091.05       338.23       218.21
0197...............  Infertility Procedures....  T                 4.0007       245.92  ...........        49.18
0198...............  Pregnancy and Neonatal      T                 1.4222        87.42        32.19        17.48
                      Care Procedures.
0200...............  Level VII Female            T                16.9328     1,040.83       243.36       208.17
                      Reproductive Proc.
0201...............  Level VI Female             T                18.5201     1,138.39       329.65       227.68
                      Reproductive Proc.
0202...............  Level X Female              T                42.9896     2,642.48       981.50       528.50
                      Reproductive Proc.
0203...............  Level IV Nerve Injections.  T                12.1702       748.08       240.33       149.62
0204...............  Level I Nerve Injections..  T                 2.2614       139.00        40.13        27.80
0206...............  Level II Nerve Injections.  T                 5.7253       351.92        75.55        70.38
0207...............  Level III Nerve Injections  T                 6.3603       390.95        86.92        78.19
0208...............  Laminotomies and            T                44.1489     2,713.74  ...........       542.75
                      Laminectomies.
0209...............  Level II MEG, Extended EEG  S                11.2463       691.29       268.73       138.26
                      Studies and Sleep Studies.
0212...............  Nervous System Injections.  T                 2.9907       183.83        65.96        36.77
0213...............  Level I MEG, Extended EEG   S                 2.2755       139.87        53.58        27.97
                      Studies and Sleep Studies.
0214...............  Electroencephalogram......  S                 1.1968        73.56        28.24        14.71
0215...............  Level I Nerve and Muscle    S                 0.5741        35.29  ...........         7.06
                      Tests.
0216...............  Level III Nerve and Muscle  S                 2.7199       167.19  ...........        33.44
                      Tests.
0218...............  Level II Nerve and Muscle   S                 1.1872        72.97  ...........        14.59
                      Tests.
0220...............  Level I Nerve Procedures..  T                17.8499     1,097.20  ...........       219.44
0221...............  Level II Nerve Procedures.  T                33.1520     2,037.79       463.62       407.56
0222...............  Implantation of             T               181.6249    11,164.12  ...........     2,232.82
                      Neurological Device.
0223...............  Implantation or Revision    T                30.8394     1,895.64  ...........       379.13
                      of Pain Management
                      Catheter.
0224...............  Implantation of Reservoir/  T                47.0342     2,891.10  ...........       578.22
                      Pump/Shunt.
0225...............  Implantation of             S               221.1512    13,593.72  ...........     2,718.74
                      Neurostimulator
                      Electrodes, Cranial Nerve.
0226...............  Implantation of Drug        T               112.6322     6,923.28  ...........     1,384.66
                      Infusion Reservoir.
0227...............  Implantation of Drug        T               174.4056    10,720.36  ...........     2,144.07
                      Infusion Device.
0228...............  Creation of Lumbar          T                39.2633     2,413.44  ...........       482.69
                      Subarachnoid Shunt.
0229...............  Transcatherter Placement    T                68.4697     4,208.70  ...........       841.74
                      of Intravascular Shunts.
0230...............  Level I Eye Tests &         S                 0.7898        48.55        14.97         9.71
                      Treatments.
0231...............  Level III Eye Tests &       S                 2.1451       131.86  ...........        26.37
                      Treatments.
0232...............  Level I Anterior Segment    T                 6.0673       372.94        93.43        74.59
                      Eye Procedures.
0233...............  Level II Anterior Segment   T                15.2259       935.91       266.33       187.18
                      Eye Procedures.
0234...............  Level III Anterior Segment  T                22.9970     1,413.58       511.31       282.72
                      Eye Procedures.
0235...............  Level I Posterior Segment   T                 3.9333       241.77        58.93        48.35
                      Eye Procedures.
0236...............  Level II Posterior Segment  T                16.5239     1,015.69  ...........       203.14
                      Eye Procedures.
0237...............  Level III Posterior         T                27.6020     1,696.64  ...........       339.33
                      Segment Eye Procedures.
0238...............  Level I Repair and Plastic  T                 2.8954       177.97  ...........        35.59
                      Eye Procedures.
0239...............  Level II Repair and         T                 7.2819       447.60  ...........        89.52
                      Plastic Eye Procedures.
0240...............  Level III Repair and        T                17.1243     1,052.60       309.52       210.52
                      Plastic Eye Procedures.
0241...............  Level IV Repair and         T                25.2550     1,552.37       384.47       310.47
                      Plastic Eye Procedures.
0242...............  Level V Repair and Plastic  T                35.2292     2,165.47       597.36       433.09
                      Eye Procedures.
0243...............  Strabismus/Muscle           T                21.2801     1,308.05       430.35       261.61
                      Procedures.
0244...............  Corneal Transplant........  T                38.2707     2,352.42       803.26       470.48
0245...............  Level I Cataract            T                14.8702       914.04       217.05       182.81
                      Procedures without IOL
                      Insert.
0246...............  Cataract Procedures with    T                23.6313     1,452.57       495.96       290.51
                      IOL Insert.

[[Page 68234]]

 
0247...............  Laser Eye Procedures        T                 5.0839       312.50       104.31        62.50
                      Except Retinal.
0248...............  Laser Retinal Procedures..  T                 5.0841       312.51        95.08        62.50
0249...............  Level II Cataract           T                29.2281     1,796.59       524.67       359.32
                      Procedures without IOL
                      Insert.
0250...............  Nasal Cauterization/        T                 1.1791        72.48        25.39        14.50
                      Packing.
0251...............  Level I ENT Procedures....  T                 2.4520       150.72  ...........        30.14
0252...............  Level II ENT Procedures...  T                 7.5511       464.15       109.16        92.83
0253...............  Level III ENT Procedures..  T                16.4266     1,009.71       282.29       201.94
0254...............  Level IV ENT Procedures...  T                23.3299     1,434.04       321.35       286.81
0256...............  Level V ENT Procedures....  T                38.1991     2,348.02  ...........       469.60
0257...............  Level I Therapeutic         S                 1.0974        67.45  ...........        13.49
                      Radiologic Procedures.
0258...............  Tonsil and Adenoid          T                22.1165     1,359.46       437.25       271.89
                      Procedures.
0259...............  Level VI ENT Procedures...  T               414.8455    25,499.72     8,698.43     5,099.94
0260...............  Level I Plain Film Except   X                 0.7093        43.60  ...........         8.72
                      Teeth.
0261...............  Level II Plain Film Except  X                 1.2224        75.14  ...........        15.03
                      Teeth Including Bone
                      Density Measurement.
0262...............  Plain Film of Teeth.......  X                 0.6550        40.26  ...........         8.05
0263...............  Level I Miscellaneous       X                 1.6956       104.23        23.77        20.85
                      Radiology Procedures.
0264...............  Level II Miscellaneous      X                 2.9586       181.86        70.27        36.37
                      Radiology Procedures.
0265...............  Level I Diagnostic and      S                 0.9923        60.99        23.63        12.20
                      Screening Ultrasound.
0266...............  Level II Diagnostic and     S                 1.5607        95.93        37.80        19.19
                      Screening Ultrasound.
0267...............  Level III Diagnostic and    S                 2.4606       151.25        60.50        30.25
                      Screening Ultrasound.
0268...............  Level I Ultrasound          S                 1.1882        73.04  ...........        14.61
                      Guidance Procedures.
0269...............  Level II Echocardiogram     S                 3.2154       197.64        75.60        39.53
                      Except Transesophageal.
0270...............  Transesophageal             S                 6.2505       384.21       141.32        76.84
                      Echocardiogram.
0272...............  Fluoroscopy...............  X                 1.2908        79.34        31.64        15.87
0274...............  Myelography...............  S                 2.5544       157.01        62.80        31.40
0275...............  Arthrography..............  S                 3.6915       226.91        69.09        45.38
0276...............  Level I Digestive           S                 1.4294        87.86        34.97        17.57
                      Radiology.
0277...............  Level II Digestive          S                 2.2176       136.31        54.52        27.26
                      Radiology.
0278...............  Diagnostic Urography......  S                 2.4159       148.50        59.40        29.70
0279...............  Level II Angiography and    S                 9.5061       584.32       150.03       116.86
                      Venography.
0280...............  Level III Angiography and   S                20.8225     1,279.92       353.85       255.98
                      Venography.
0282...............  Miscellaneous Computerized  S                 1.5379        94.53        37.81        18.91
                      Axial Tomography.
0283...............  Computed Tomography with    S                 4.0825       250.94       100.37        50.19
                      Contrast.
0284...............  Magnetic Resonance Imaging  S                 6.1231       376.37       148.40        75.27
                      and Magnetic Resonance
                      Angiography with Contrast.
0288...............  Bone Density:Axial          S                 1.1755        72.26        28.90        14.45
                      Skeleton.
0293...............  Level V Anterior Segment    T                51.9894     3,195.68     1,128.29       639.14
                      Eye Procedures.
0296...............  Level II Therapeutic        S                 2.6802       164.75        53.99        32.95
                      Radiologic Procedures.
0297...............  Level III Therapeutic       S                 3.6392       223.69        89.47        44.74
                      Radiologic Procedures.
0298...............  Level IV Therapeutic        S                 8.3906       515.75       206.30       103.15
                      Radiologic Procedures.
0299...............  Miscellaneous Radiation     S                 5.8839       361.67  ...........        72.33
                      Treatment.
0300...............  Level I Radiation Therapy.  S                 1.4826        91.13  ...........        18.23
0301...............  Level II Radiation Therapy  S                 2.2295       137.04  ...........        27.41
0302...............  Computer Assisted           S                 4.9138       302.04       105.94        60.41
                      Navigational Procedures.
0303...............  Treatment Device            X                 2.9430       180.90        66.95        36.18
                      Construction.
0304...............  Level I Therapeutic         X                 1.5735        96.72        38.68        19.34
                      Radiation Treatment
                      Preparation.
0305...............  Level II Therapeutic        X                 3.9723       244.17        91.38        48.83
                      Radiation Treatment
                      Preparation.
0307...............  Myocardial Positron         S                11.8963       731.24       292.49       146.25
                      Emission Tomography (PET)
                      imaging.
0308...............  Non-Myocardial Positron     S                13.9166       855.43  ...........       171.09
                      Emission Tomography (PET)
                      imaging.
0309...............  Level II Ultrasound         S                 2.1012       129.16  ...........        25.83
                      Guidance Procedures.
0310...............  Level III Therapeutic       X                13.8081       848.76       325.27       169.75
                      Radiation Treatment
                      Preparation.
0312...............  Radioelement Applications.  S                 4.8569       298.54  ...........        59.71
0313...............  Brachytherapy.............  S                12.8473       789.70  ...........       157.94
0314...............  Hyperthermic Therapies....  S                 3.3461       205.68        60.88        41.14
0315...............  Level II Implantation of    T               242.9363    14,932.81  ...........     2,986.56
                      Neurostimulator.
0320...............  Electroconvulsive Therapy.  S                 5.5676       342.23        80.06        68.45
0321...............  Biofeedback and Other       S                 1.3384        82.27        21.72        16.45
                      Training.
0322...............  Brief Individual            S                 1.1798        72.52  ...........        14.50
                      Psychotherapy.
0323...............  Extended Individual         S                 1.7066       104.90  ...........        20.98
                      Psychotherapy.
0324...............  Family Psychotherapy......  S                 2.1633       132.97  ...........        26.59
0325...............  Group Psychotherapy.......  S                 1.0765        66.17        14.47        13.23
0330...............  Dental Procedures.........  S                 7.0550       433.66  ...........        86.73
0332...............  Computed Tomography         S                 3.0908       189.99        75.24        38.00
                      without Contrast.
0333...............  Computed Tomography         S                 4.8405       297.54       119.01        59.51
                      without Contrast followed
                      by Contrast).
0335...............  Magnetic Resonance          S                 4.5523       279.82       111.92        55.96
                      Imaging, Miscellaneous.
0336...............  Magnetic Resonance Imaging  S                 5.6745       348.80       139.51        69.76
                      and Magnetic Resonance
                      Angiography without
                      Contrast.

[[Page 68235]]

 
0337...............  Magnetic Resonance Imaging  S                 8.1155       498.84       199.53        99.77
                      and Magnetic Resonance
                      Angiography without
                      Contrast followed by
                      Contrast.
0339...............  Observation...............  S                 7.2039       442.81  ...........        88.56
0340...............  Minor Ancillary Procedures  X                 0.6102        37.51  ...........         7.50
0341...............  Skin Tests................  X                 0.0914         5.62         2.24         1.12
0342...............  Level I Pathology.........  X                 0.0824         5.06         2.02         1.01
0343...............  Level III Pathology.......  X                 0.5211        32.03        10.84         6.41
0344...............  Level IV Pathology........  X                 0.7927        48.73        15.66         9.75
0345...............  Level I Transfusion         X                 0.2178        13.39         2.87         2.68
                      Laboratory Procedures.
0346...............  Level II Transfusion        X                 0.3484        21.42         4.39         4.28
                      Laboratory Procedures.
0347...............  Level III Transfusion       X                 0.7423        45.63        11.28         9.13
                      Laboratory Procedures.
0348...............  Fertility Laboratory        X                 0.8321        51.15  ...........        10.23
                      Procedures.
0350...............  Administration of flu and   S                 0.3945        24.25  ...........         0.00
                      PPV vaccine.
0360...............  Level I Alimentary Tests..  X                 1.4154        87.00        33.88        17.40
0361...............  Level II Alimentary Tests.  X                 3.8887       239.03        83.23        47.81
0362...............  Contact Lens and Spectacle  X                 0.5865        36.05  ...........         7.21
                      Services.
0363...............  Level I                     X                 0.8525        52.40        17.44        10.48
                      Otorhinolaryngologic
                      Function Tests.
0364...............  Level I Audiometry........  X                 0.4627        28.44         7.06         5.69
0365...............  Level II Audiometry.......  X                 1.2419        76.34        18.52        15.27
0366...............  Level III Audiometry......  X                 1.8511       113.78        26.14        22.76
0367...............  Level I Pulmonary Test....  X                 0.6277        38.58        14.68         7.72
0368...............  Level II Pulmonary Tests..  X                 0.9454        58.11        22.77        11.62
0369...............  Level III Pulmonary Tests.  X                 2.7669       170.08        44.18        34.02
0370...............  Allergy Tests.............  X                 1.0270        63.13  ...........        12.63
0372...............  Therapeutic Phlebotomy....  X                 0.5723        35.18        10.09         7.04
0373...............  Level I Neuropsychological  X                 1.7682       108.69  ...........        21.74
                      Testing.
0374...............  Monitoring Psychiatric      X                 1.1418        70.18  ...........        14.04
                      Drugs.
0375...............  Ancillary Outpatient        S                58.0781     3,569.94  ...........       713.99
                      Services When Patient
                      Expires.
0376...............  Level II Cardiac Imaging..  S                 4.9832       306.31       119.77        61.26
0377...............  Level III Cardiac Imaging.  S                 6.5012       399.62       158.84        79.92
0378...............  Level II Pulmonary Imaging  S                 5.0975       313.33       125.33        62.67
0379...............  Injection adenosine 6 MG..  K            ...........        30.49  ...........         6.10
0381...............  Single Allergy Tests......  X                 0.2688        16.52  ...........         3.30
0382...............  Level II                    X                 2.8460       174.94        69.97        34.99
                      Neuropsychological
                      Testing.
0384...............  GI Procedures with Stents.  T                22.9475     1,410.54       295.41       282.11
0385...............  Level I Prosthetic          S                79.2092     4,868.83  ...........       973.77
                      Urological Procedures.
0386...............  Level II Prosthetic         S               137.3897     8,445.07  ...........     1,689.01
                      Urological Procedures.
0387...............  Level II Hysteroscopy.....  T                34.0155     2,090.86       655.55       418.17
0388...............  Discography...............  S                15.9758       982.00       289.72       196.40
0389...............  Level I Non-imaging         S                 1.3754        84.54        33.81        16.91
                      Nuclear Medicine.
0390...............  Level I Endocrine Imaging.  S                 2.3432       144.03        57.61        28.81
0391...............  Level II Endocrine Imaging  S                 2.7146       166.86        66.18        33.37
0392...............  Level II Non-imaging        S                 2.0057       123.29        49.31        24.66
                      Nuclear Medicine.
0393...............  Red Cell/Plasma Studies...  S                 3.7562       230.89        82.04        46.18
0394...............  Hepatobiliary Imaging.....  S                 4.3774       269.07       102.61        53.81
0395...............  GI Tract Imaging..........  S                 3.6526       224.52        89.73        44.90
0396...............  Bone Imaging..............  S                 3.9174       240.79        95.02        48.16
0397...............  Vascular Imaging..........  S                 2.4204       148.78        49.58        29.76
0398...............  Level I Cardiac Imaging...  S                 4.1265       253.65       100.06        50.73
0399...............  Nuclear Medicine Add-on     S                 1.5054        92.53        35.80        18.51
                      Imaging.
0400...............  Hematopoietic Imaging.....  S                 3.9073       240.17        93.22        48.03
0401...............  Level I Pulmonary Imaging.  S                 3.1802       195.48        78.19        39.10
0402...............  Brain Imaging.............  S                 4.6418       285.32       114.12        57.06
0403...............  CSF Imaging...............  S                 3.4923       214.66        83.35        42.93
0404...............  Renal and Genitourinary     S                 3.4209       210.28        84.11        42.06
                      Studies Level I.
0405...............  Renal and Genitourinary     S                 4.0378       248.20        98.77        49.64
                      Studies Level II.
0406...............  Level I Tumor/Infection     S                 3.9934       245.47        98.18        49.09
                      Imaging.
0407...............  Level I Radionuclide        S                 3.1779       195.34        78.13        39.07
                      Therapy.
0408...............  Level II Tumor/Infection    S                 5.9245       364.17  ...........        72.83
                      Imaging.
0409...............  Red Blood Cell Tests......  X                 0.1227         7.54         2.20         1.51
0411...............  Respiratory Procedures....  S                 0.3848        23.65  ...........         4.73
0412...............  IMRT Treatment Delivery...  S                 5.4731       336.42  ...........        67.28
0413...............  Level II Radionuclide       S                 5.2957       325.52  ...........        65.10
                      Therapy.
0415...............  Level II Endoscopy Lower    T                22.0099     1,352.90       459.92       270.58
                      Airway.
0416...............  Level I Intravascular and   S                32.5472     2,000.61  ...........       400.12
                      Intracardiac Ultrasound
                      and Flow Reserve.
0417...............  Computerized                S                 3.2393       199.11  ...........        39.82
                      Reconstruction.
0418...............  Insertion of Left           T               307.2828    18,888.06  ...........     3,777.61
                      Ventricular Pacing Elect..
0421...............  Prolonged Physiologic       X                 1.6270       100.01  ...........        20.00
                      Monitoring.

[[Page 68236]]

 
0422...............  Level II Upper GI           T                25.7552     1,583.12       448.81       316.62
                      Procedures.
0423...............  Level II Percutaneous       T                37.3604     2,296.47  ...........       459.29
                      Abdominal and Biliary
                      Procedures.
0425...............  Level II Arthroplasty with  T               107.1942     6,589.01     1,378.01     1,317.80
                      Prosthesis.
0426...............  Level II Strapping and      S                 2.2777       140.01  ...........        28.00
                      Cast Application.
0427...............  Level III Tube Changes and  T                11.6575       716.56  ...........       143.31
                      Repositioning.
0428...............  Level III Sigmoidoscopy     T                20.6375     1,268.55  ...........       253.71
                      and Anoscopy.
0429...............  Level V Cystourethroscopy   T                43.1004     2,649.30  ...........       529.86
                      and other Genitourinary
                      Procedures.
0432...............  Health and Behavior         S                 0.6072        37.32  ...........         7.46
                      Services.
0433...............  Level II Pathology........  X                 0.2557        15.72         5.93         3.14
0434...............  Cardiac Defect Repair.....  T                88.0728     5,413.66  ...........     1,082.73
0436...............  Level I Drug                S                 0.1809        11.12  ...........         2.22
                      Administration.
0437...............  Level II Drug               S                 0.3945        24.25  ...........         4.85
                      Administration.
0438...............  Level III Drug              S                 0.7942        48.82  ...........         9.76
                      Administration.
0439...............  Level IV Drug               S                 1.5848        97.41  ...........        19.48
                      Administration.
0440...............  Level V Drug                S                 1.8090       111.20  ...........        22.24
                      Administration.
0441...............  Level VI Drug               S                 2.4851       152.75  ...........        30.55
                      Administration.
0442...............  Dosimetric Drug             S                22.3666     1,374.83  ...........       274.97
                      Administration.
0443...............  Overnight Pulse Oximetry..  X                 1.0409        63.98        25.59        12.80
0604...............  Level 1 Hospital Clinic     V                 0.8242        50.66  ...........        10.13
                      Visits.
0605...............  Level 2 Hospital Clinic     V                 0.9840        60.48  ...........        12.10
                      Visits.
0606...............  Level 3 Hospital Clinic     V                 1.3646        83.88  ...........        16.78
                      Visits.
0607...............  Level 4 Hospital Clinic     V                 1.7096       105.09  ...........        21.02
                      Visits.
0608...............  Level 5 Hospital Clinic     V                 2.1794       133.96  ...........        26.79
                      Visits.
0609...............  Level 1 Emergency Visits..  V                 0.8136        50.01        12.70        10.00
0613...............  Level 2 Emergency Visits..  V                 1.3497        82.96        21.06        16.59
0614...............  Level 3 Emergency Visits..  V                 2.1150       130.00        34.50        26.00
0615...............  Level 4 Emergency Visits..  V                 3.4163       209.99        48.49        42.00
0616...............  Level 5 Emergency Visits..  V                 5.2915       325.26        75.11        65.05
0617...............  Critical Care.............  S                 6.5894       405.04       111.59        81.01
0618...............  Trauma Response with        S                 8.0455       494.54       197.81        98.91
                      Critical Care.
0621...............  Level I Vascular Access     T                 8.7846       539.97  ...........       107.99
                      Procedures.
0622...............  Level II Vascular Access    T                22.6665     1,393.26  ...........       278.65
                      Procedures.
0623...............  Level III Vascular Access   T                28.5032     1,752.03  ...........       350.41
                      Procedures.
0624...............  Minor Vascular Access       X                 0.5145        31.63        12.65         6.33
                      Device Procedures.
0625...............  Level IV Vascular Access    T                83.4609     5,130.17  ...........     1,026.03
                      Procedures.
0648...............  Level IV Breast Surgery...  T                51.2269     3,148.82  ...........       629.76
0651...............  Complex Interstitial        S                16.8462     1,035.50  ...........       207.10
                      Radiation Source
                      Application.
0652...............  Insertion of                T                29.5416     1,815.86  ...........       363.17
                      Intraperitoneal and
                      Pleural Catheters.
0653...............  Vascular Reconstruction/    T                32.3818     1,990.44  ...........       398.09
                      Fistula Repair with
                      Device.
0654...............  Insertion/Replacement of a  T               112.7719     6,931.86  ...........     1,386.37
                      permanent dual chamber
                      pacemaker.
0655...............  Insertion/Replacement/      T               152.6392     9,382.43  ...........     1,876.49
                      Conversion of a permanent
                      dual chamber pacemaker.
0656...............  Transcatheter Placement of  T               108.3003     6,657.00  ...........     1,331.40
                      Intracoronary Drug-
                      Eluting Stents.
0657...............  Placement of Tissue Clips.  S                 1.7369       106.76  ...........        21.35
0658...............  Percutaneous Breast         T                 6.4387       395.77  ...........        79.15
                      Biopsies.
0659...............  Hyperbaric Oxygen.........  S                 1.5906        97.77  ...........        19.55
0660...............  Level II                    X                 1.4461        88.89        28.06        17.78
                      Otorhinolaryngologic
                      Function Tests.
0661...............  Level V Pathology.........  X                 2.5255       155.24        62.09        31.05
0662...............  CT Angiography............  S                 4.8552       298.44       118.88        59.69
0663...............  Level I Electronic          S                 1.1067        68.03        17.45        13.61
                      Analysis of
                      Neurostimulator Pulse
                      Generators.
0664...............  Level I Proton Beam         S                18.8926     1,161.29  ...........       232.26
                      Radiation Therapy.
0665...............  Bone                        S                 0.5497        33.79        13.51         6.76
                      Density:AppendicularSkele
                      ton.
0667...............  Level II Proton Beam        S                22.6031     1,389.37  ...........       277.87
                      Radiation Therapy.
0668...............  Level I Angiography and     S                 6.2463       383.95        88.26        76.79
                      Venography.
0670...............  Level II Intravascular and  S                32.2854     1,984.52       536.10       396.90
                      Intracardiac Ultrasound
                      and Flow Reserve.
0672...............  Level IV Posterior Segment  T                37.4290     2,300.69  ...........       460.14
                      Eye Procedures.
0673...............  Level IV Anterior Segment   T                37.8967     2,329.43       649.56       465.89
                      Eye Procedures.
0674...............  Prostate Cryoablation.....  T               108.7566     6,685.05  ...........     1,337.01
0675...............  Prostatic Thermotherapy...  T                41.1375     2,528.64  ...........       505.73
0676...............  Thrombolysis and            T                 2.0726       127.40  ...........        25.48
                      Thrombectomy.
0678...............  External Counterpulsation.  T                 1.7418       107.06  ...........        21.41
0679...............  Level II Resuscitation and  S                 5.5233       339.51        95.30        67.90
                      Cardioversion.
0680...............  Insertion of Patient        S                72.6022     4,462.71  ...........       892.54
                      Activated Event Recorders.
0681...............  Knee Arthroplasty.........  T               205.6815    12,642.83  ...........     2,528.57
0682...............  Level V Debridement &       T                 6.8832       423.10       158.65        84.62
                      Destruction.
0683...............  Level II Photochemotherapy  S                 2.6734       164.33  ...........        32.87
0685...............  Level III Needle Biopsy/    T                 6.1384       377.32       115.47        75.46
                      Aspiration Except Bone
                      Marrow.

[[Page 68237]]

 
0686...............  Level III Skin Repair.....  T                14.0346       862.68  ...........       172.54
0687...............  Revision/Removal of         T                17.8334     1,096.18       438.47       219.24
                      Neurostimulator
                      Electrodes.
0688...............  Revision/Removal of         T                35.5702     2,186.43       874.57       437.29
                      Neurostimulator Pulse
                      Generator Receiver.
0689...............  Electronic Analysis of      S                 0.6003        36.90  ...........         7.38
                      Cardioverter-
                      defibrillators.
0690...............  Electronic Analysis of      S                 0.3613        22.21         8.67         4.44
                      Pacemakers and other
                      Cardiac Devices.
0691...............  Electronic Analysis of      S                 2.8942       177.90        60.61        35.58
                      Programmable Shunts/Pumps.
0692...............  Level II Electronic         S                 1.9323       118.77        30.16        23.75
                      Analysis of
                      Neurostimulator Pulse
                      Generators.
0693...............  Breast Reconstruction.....  T                36.9988     2,274.24       721.30       454.85
0694...............  Mohs Surgery..............  T                 3.7292       229.23        91.69        45.85
0695...............  Level VII Debridement &     T                20.4276     1,255.64       266.59       251.13
                      Destruction.
0697...............  Level I Echocardiogram      S                 1.5973        98.18        35.99        19.64
                      Except Transesophageal.
0698...............  Level II Eye Tests &        S                 1.1607        71.35  ...........        14.27
                      Treatments.
0699...............  Level IV Eye Tests &        T                14.3845       884.19  ...........       176.84
                      Treatments.
0700...............  Antepartum Manipulation...  T                 2.3864       146.69  ...........        29.34
0701...............  Sr89 strontium............  H            ...........  ...........  ...........  ...........
0702...............  Sm 153 lexidronm..........  H            ...........  ...........  ...........  ...........
0704...............  In111 satumomab...........  H            ...........  ...........  ...........  ...........
0705...............  Tc99m tetrofosmin.........  H            ...........  ...........  ...........  ...........
0722...............  Tc99m pentetate...........  H            ...........  ...........  ...........  ...........
0723...............  Co57/58...................  H            ...........  ...........  ...........  ...........
0724...............  Co57 cyano................  H            ...........  ...........  ...........  ...........
0726...............  Dexrazoxane HCl injection.  K            ...........       180.13  ...........        36.03
0728...............  Filgrastim 300 mcg          K            ...........       188.07  ...........        37.61
                      injection.
0730...............  Pamidronate disodium /30    K            ...........        34.80  ...........         6.96
                      MG.
0731...............  Sargramostim injection....  K            ...........        25.55  ...........         5.11
0732...............  Mesna injection...........  K            ...........        10.10  ...........         2.02
0735...............  Ampho b cholesteryl         K            ...........        12.00  ...........         2.40
                      sulfate.
0736...............  Amphotericin b liposome     K            ...........        21.25  ...........         4.25
                      inj.
0737...............  Nitrogen N-13 ammonia.....  H            ...........  ...........  ...........  ...........
0738...............  Rasburicase...............  K            ...........       121.26  ...........        24.25
0739...............  Tc99m depreotide..........  H            ...........  ...........  ...........  ...........
0740...............  Tc99m gluceptate..........  H            ...........  ...........  ...........  ...........
0741...............  Cr51 chromate.............  H            ...........  ...........  ...........  ...........
0742...............  Tc99m labeled rbc.........  H            ...........  ...........  ...........  ...........
0743...............  Tc99m mertiatide..........  H            ...........  ...........  ...........  ...........
0744...............  Plague vaccine, im........  K            ...........       150.00  ...........        30.00
0746...............  Dacarbazine 100 mg inj....  K            ...........         4.90  ...........         0.98
0747...............  Chlorothiazide sodium inj.  K            ...........       123.84  ...........        24.77
0748...............  Bleomycin sulfate           K            ...........        37.62  ...........         7.52
                      injection.
0750...............  Dolasetron mesylate.......  K            ...........         6.89  ...........         1.38
0751...............  Mechlorethamine hcl inj...  K            ...........       141.61  ...........        28.32
0752...............  Dactinomycin actinomycin d  K            ...........       493.43  ...........        98.69
0753...............  Spectinomycn di-hcl inj...  K            ...........        30.08  ...........         6.02
0759...............  Naltrexone, depot form....  K            ...........         1.94  ...........         0.39
0760...............  Anadulafungin injection...  G            ...........         1.91  ...........         0.38
0763...............  Dolasetron mesylate oral..  K            ...........        48.91  ...........         9.78
0764...............  Granisetron HCl injection.  K            ...........         7.21  ...........         1.44
0765...............  Granisetron HCl 1 mg oral.  K            ...........        41.18  ...........         8.24
0766...............  Apomorphine hydrochloride.  K            ...........         2.92  ...........         0.58
0767...............  Enfuvirtide injection.....  K            ...........        21.82  ...........         4.36
0768...............  Ondansetron hcl injection.  K            ...........         3.72  ...........         0.74
0769...............  Ondansetron HCl 8mg oral..  K            ...........        36.06  ...........         7.21
0800...............  Leuprolide acetate /3.75    K            ...........       437.58  ...........        87.52
                      MG.
0802...............  Etoposide oral 50 MG......  K            ...........        32.01  ...........         6.40
0804...............  Immune globulin             K            ...........         7.08  ...........         1.42
                      subcutaneous.
0805...............  Mecasermin injection......  K            ...........        11.93  ...........         2.39
0806...............  Hyaluronidase recombinant.  G            ...........         0.40  ...........         0.08
0807...............  Aldesleukin/single use      K            ...........       726.69  ...........       145.34
                      vial.
0808...............  Nabilone oral.............  K            ...........        16.96  ...........         3.39
0809...............  Bcg live intravesical vac.  K            ...........       113.44  ...........        22.69
0810...............  Goserelin acetate implant.  K            ...........       199.12  ...........        39.82
0811...............  Carboplatin injection.....  K            ...........        10.12  ...........         2.02
0812...............  Carmus bischl nitro inj...  K            ...........       139.84  ...........        27.97
0814...............  Asparaginase injection....  K            ...........        54.46  ...........        10.89
0820...............  Daunorubicin..............  K            ...........        24.56  ...........         4.91
0821...............  Daunorubicin citrate        K                  56.21  ...........        11.24
                      liposom.
0823...............  Docetaxel.................  K            ...........       302.68  ...........        60.54
0825...............  Nelarabine injection......  K            ...........        83.10  ...........        16.62
0827...............  Floxuridine injection.....  K            ...........        64.17  ...........        12.83

[[Page 68238]]

 
0828...............  Gemcitabine HCl...........  K            ...........       121.30  ...........        24.26
0829...............  Technetium TC-99m aerosol.  H            ...........  ...........  ...........  ...........
0830...............  Irinotecan injection......  K            ...........       126.88  ...........        25.38
0831...............  Ifosfomide injection......  K            ...........        52.39  ...........        10.48
0832...............  Idarubicin hcl injection..  K            ...........       308.97  ...........        61.79
0834...............  Interferon alfa-2a inj....  K            ...........        37.56  ...........         7.51
0835...............  Inj cosyntropin per 0.25    K            ...........        62.91  ...........        12.58
                      MG.
0836...............  Interferon alfa-2b inj....  K            ...........        13.75  ...........         2.75
0838...............  Interferon gamma 1-b inj..  K            ...........       289.87  ...........        57.97
0840...............  Inj melphalan hydrochl 50   K            ...........     1,194.15  ...........       238.83
                      MG.
0842...............  Fludarabine phosphate inj.  K            ...........       243.82  ...........        48.76
0843...............  Pegaspargase/singl dose     K            ...........     1,687.04  ...........       337.41
                      vial.
0844...............  Pentostatin injection.....  K            ...........     2,034.63  ...........       406.93
0849...............  Rituximab cancer treatment  K            ...........       481.69  ...........        96.34
0850...............  Streptozocin injection....  K            ...........       152.92  ...........        30.58
0851...............  Thiotepa injection........  K            ...........        44.58  ...........         8.92
0852...............  Topotecan.................  K            ...........       813.08  ...........       162.62
0855...............  Vinorelbine tartrate/10 mg  K            ...........        22.82  ...........         4.56
0856...............  Porfimer sodium...........  K            ...........     2,505.40  ...........       501.08
0858...............  Inj cladribine per 1 MG...  K            ...........        37.87  ...........         7.57
0860...............  Plicamycin (mithramycin)    K            ...........        61.36  ...........        12.27
                      inj.
0861...............  Leuprolide acetate          K            ...........        11.10  ...........         2.22
                      injeciton.
0862...............  Mitomycin 5 MG inj........  K            ...........        18.31  ...........         3.66
0863...............  Paclitaxel injection......  K            ...........        14.35  ...........         2.87
0864...............  Mitoxantrone hydrochl / 5   K            ...........       223.27  ...........        44.65
                      MG.
0865...............  Interferon alfa-n3 inj....  K            ...........        39.48  ...........         7.90
0868...............  Oral aprepitant...........  G            ...........         4.85  ...........         0.97
0876...............  Caffeine citrate injection  K            ...........         3.54  ...........         0.71
0884...............  Rho d immune globulin inj.  K            ...........        80.52  ...........        16.10
0887...............  Azathioprine parenteral...  K            ...........        49.17  ...........         9.83
0888...............  Cyclosporine oral 100 mg..  K            ...........         3.66  ...........         0.73
0890...............  Lymphocyte immune globulin  K            ...........       315.76  ...........        63.15
0891...............  Tacrolimus oral per 1 MG..  K            ...........         3.55  ...........         0.71
0892...............  Edetate calcium disodium    K            ...........        40.19  ...........         8.04
                      inj.
0895...............  Deferoxamine mesylate inj.  K            ...........        14.84  ...........         2.97
0896...............  Sodium Hyaluronate          K            ...........       124.68  ...........        24.94
                      Injection.
0900...............  Alglucerase injection.....  K            ...........        39.22  ...........         7.84
0901...............  Alpha 1 proteinase          K            ...........         3.31  ...........         0.66
                      inhibitor.
0902...............  Botulinum toxin a per unit  K            ...........         5.04  ...........         1.01
0903...............  Cytomegalovirus imm IV /    K            ...........       853.18  ...........       170.64
                      vial.
0906...............  RSV-ivig..................  K            ...........        16.18  ...........         3.24
0910...............  Interferon beta-1b / .25    K            ...........        90.00  ...........        18.00
                      MG.
0911...............  Inj streptokinase /250000   K            ...........        79.50  ...........        15.90
                      IU.
0912...............  Interferon alfacon-1......  K            ...........         4.65  ...........         0.93
0913...............  Ganciclovir long act        K            ...........     4,766.14  ...........       953.23
                      implant.
0916...............  Injection imiglucerase /    K            ...........         3.91  ...........         0.78
                      unit.
0917...............  Adenosine injection.......  K            ...........        30.49  ...........         6.10
0925...............  Factor viii...............  K            ...........         0.69  ...........         0.14
0926...............   Factor VIII (porcine)....  K            ...........         1.33  ...........         0.27
0927...............  Factor viii recombinant...  K            ...........         1.06  ...........         0.21
0928...............  Factor ix complex.........  K            ...........         0.72  ...........         0.14
0929...............  Anti-inhibitor............  K            ...........         1.36  ...........         0.27
0930...............  Antithrombin iii injection  K            ...........         1.62  ...........         0.32
0931...............  Factor IX non-recombinant.  K            ...........         0.90  ...........         0.18
0932...............  Factor IX recombinant.....  K            ...........         0.99  ...........         0.20
0935...............  Clonidine hydrochloride...  K            ...........        66.04  ...........        13.21
0949...............  Frozen plasma, pooled, sd.  K                 0.9346        57.45  ...........        11.49
0950...............  Whole blood for             K                 2.1472       131.98  ...........        26.40
                      transfusion.
0952...............  Cryoprecipitate each unit.  K                 0.7905        48.59  ...........         9.72
0954...............  RBC leukocytes reduced....  K                 2.8590       175.74  ...........        35.15
0955...............  Plasma, frz between 8-      K                 1.2489        76.77  ...........        15.35
                      24hour.
0956...............  Plasma protein              K                 0.8339        51.26  ...........        10.25
                      fract,5%,50ml.
0957...............  Platelets, each unit......  K                 0.9590        58.95  ...........        11.79
0958...............  Plaelet rich plasma unit..  K                 3.4048       209.29  ...........        41.86
0959...............  Red blood cells unit......  K                 2.1073       129.53  ...........        25.91
0960...............  Washed red blood cells      K                 3.4331       211.03  ...........        42.21
                      unit.
0961...............  Albumin (human), 5%, 50ml.  K            ...........        29.68  ...........         5.94
0963...............  Albumin (human), 5%, 250    K            ...........        76.81  ...........        15.36
                      ml.
0964...............  Albumin (human), 25%, 20    K            ...........        28.80  ...........         5.76
                      ml.

[[Page 68239]]

 
0965...............  Albumin (human), 25%, 50ml  K            ...........        65.26  ...........        13.05
0966...............  Plasmaprotein fract,        K                 3.8746       238.16  ...........        47.63
                      5%,250ml.
0967...............  Blood split unit..........  K                 2.2323       137.22  ...........        27.44
0968...............  Platelets leukoreduced      K                 2.0390       125.33  ...........        25.07
                      irrad.
0969...............  RBC leukoreduced            K                 3.5394       217.56  ...........        43.51
                      irradiated.
1009...............  Cryoprecipitatereducedplas  K                 1.3404        82.39  ...........        16.48
                      ma.
1010...............  Blood, l/r, cmv-neg.......  K                 2.5493       156.70  ...........        31.34
1011...............  Platelets, hla-m, l/r,      K                10.9263       671.62  ...........       134.32
                      unit.
1013...............  Platelets leukocytes        K                 1.5469        95.08  ...........        19.02
                      reduced.
1016...............  Blood, l/r, froz/degly/     K                 3.4335       211.05  ...........        42.21
                      wash.
1017...............  Plt, aph/pher, l/r, cmv-    K                 6.4556       396.81  ...........        79.36
                      neg.
1018...............  Blood, l/r, irradiated....  K                 2.3472       144.28  ...........        28.86
1019...............  Plate pheres leukoredu      K                10.0443       617.40  ...........       123.48
                      irrad.
1020...............  Plt, pher, l/r cmv-neg,     K                11.4755       705.38  ...........       141.08
                      irr.
1021...............  RBC, frz/deg/wsh, l/r,      K                 8.0727       496.21  ...........        99.24
                      irrad.
1022...............  RBC, l/r, cmv-neg, irrad..  K                 4.2653       262.18  ...........        52.44
1032...............  Aud osseo dev, int/ext      H            ...........  ...........  ...........  ...........
                      comp.
1045...............  I131 iodobenguate, dx.....  H            ...........  ...........  ...........  ...........
1052...............  Injection, voriconazole...  K            ...........         4.66  ...........         0.93
1064...............  I131 iodide cap, rx.......  H            ...........  ...........  ...........  ...........
1083...............  Adalimumab injection......  K            ...........       308.33  ...........        61.67
1084...............  Denileukin diftitox, 300    K            ...........     1,403.23  ...........       280.65
                      mcg.
1086...............  Temozolomide..............  K            ...........         7.30  ...........         1.46
1088...............  Iodine I-131 iodide cap,    H            ...........  ...........  ...........  ...........
                      dx.
1096...............  Tc99m exametazime.........  H            ...........  ...........  ...........  ...........
1150...............  I131 iodide sol, rx.......  H            ...........  ...........  ...........  ...........
1166...............  Cytarabine liposome.......  K            ...........       396.66  ...........        79.33
1167...............  Inj, epirubicin hcl, 2 mg.  K            ...........        24.67  ...........         4.93
1178...............  Busulfan injection........  K            ...........         8.89  ...........         1.78
1203...............  Verteporfin injection.....  K            ...........         8.91  ...........         1.78
1207...............  Octreotide injection,       K            ...........        93.35  ...........        18.67
                      depot.
1280...............  Corticotropin injection...  K            ...........       116.60  ...........        23.32
1330...............  Ergonovine maleate          K            ...........        33.11  ...........         6.62
                      injection.
1436...............  Etidronate disodium inj...  K            ...........        71.41  ...........        14.28
1491...............  New Technology--Level IA    S            ...........         5.00  ...........         1.00
                      ($0-$10).
1492...............  New Technology--Level IB    S            ...........        15.00  ...........         3.00
                      ($10-$20).
1493...............  New Technology--Level IC    S            ...........        25.00  ...........         5.00
                      ($20-$30).
1494...............  New Technology--Level ID    S            ...........        35.00  ...........         7.00
                      ($30-$40).
1495...............  New Technology--Level IE    S            ...........        45.00  ...........         9.00
                      ($40-$50).
1496...............  New Technology--Level IA    T            ...........         5.00  ...........         1.00
                      ($0-$10).
1497...............  New Technology--Level       T            ...........        15.00  ...........         3.00
                      IB($10-$20).
1498...............  New Technology--Level IC    T            ...........        25.00  ...........         5.00
                      ($20-$30).
1499...............  New Technology--Level       T            ...........        35.00  ...........         7.00
                      ID($30-$40).
1500...............  New Technology--Level IE    T            ...........        45.00  ...........         9.00
                      ($40-$50).
1502...............  New Technology--Level II    S            ...........        75.00  ...........        15.00
                      ($50-$100).
1503...............  New Technology--Level III   S            ...........       150.00  ...........        30.00
                      ($100-$200).
1504...............  New Technology--Level IV    S            ...........       250.00  ...........        50.00
                      ($200-$300).
1505...............  New Technology--Level V     S            ...........       350.00  ...........        70.00
                      ($300-$400).
1506...............  New Technology--Level VI    S            ...........       450.00  ...........        90.00
                      ($400-$500).
1507...............  New Technology--Level VII   S            ...........       550.00  ...........       110.00
                      ($500-$600).
1508...............  New Technology--Level VIII  S            ...........       650.00  ...........       130.00
                      ($600-$700).
1509...............  New Technology--Level IX    S            ...........       750.00  ...........       150.00
                      ($700-$800).
1510...............  New Technology--Level X     S            ...........       850.00  ...........       170.00
                      ($800-$900).
1511...............  New Technology--Level XI    S            ...........       950.00  ...........       190.00
                      ($900-$1000).
1512...............  New Technology--Level XII   S            ...........     1,050.00  ...........       210.00
                      ($1000-$1100).
1513...............  New Technology--Level XIII  S            ...........     1,150.00  ...........       230.00
                      ($1100-$1200).
1514...............  New Technology--Level XIV   S            ...........     1,250.00  ...........       250.00
                      ($1200-$1300).
1515...............  New Technology--Level XV    S            ...........     1,350.00  ...........       270.00
                      ($1300-$1400).
1516...............  New Technology--Level XVI   S            ...........     1,450.00  ...........       290.00
                      ($1400-$1500).
1517...............  New Technology--Level XVII  S            ...........     1,550.00  ...........       310.00
                      ($1500-$1600).
1518...............  New Technology--Level       S            ...........     1,650.00  ...........       330.00
                      XVIII ($1600-$1700).
1519...............  New Technology--Level IXX   S            ...........     1,750.00  ...........       350.00
                      ($1700-$1800).
1520...............  New Technology--Level XX    S            ...........     1,850.00  ...........       370.00
                      ($1800-$1900).
1521...............  New Technology--Level XXI   S            ...........     1,950.00  ...........       390.00
                      ($1900-$2000).
1522...............  New Technology--Level XXII  S            ...........     2,250.00  ...........       450.00
                      ($2000-$2500).
1523...............  New Technology--Level       S            ...........     2,750.00  ...........       550.00
                      XXIII ($2500-$3000).
1524...............  New Technology--Level XXIV  S            ...........     3,250.00  ...........       650.00
                      ($3000-$3500).
1525...............  New Technology--Level XXV   S            ...........     3,750.00  ...........       750.00
                      ($3500-$4000).
1526...............  New Technology--Level XXVI  S            ...........     4,250.00  ...........       850.00
                      ($4000-$4500).

[[Page 68240]]

 
1527...............  New Technology--Level       S            ...........     4,750.00  ...........       950.00
                      XXVII ($4500-$5000).
1528...............  New Technology--Level       S            ...........     5,250.00  ...........     1,050.00
                      XXVIII ($5000-$5500).
1529...............  New Technology--Level XXIX  S            ...........     5,750.00  ...........     1,150.00
                      ($5500-$6000).
1530...............  New Technology--Level XXX   S            ...........     6,250.00  ...........     1,250.00
                      ($6000-$6500).
1531...............  New Technology--Level XXXI  S            ...........     6,750.00  ...........     1,350.00
                      ($6500-$7000).
1532...............  New Technology--Level       S            ...........     7,250.00  ...........     1,450.00
                      XXXII ($7000-$7500).
1533...............  New Technology--Level       S            ...........     7,750.00  ...........     1,550.00
                      XXXIII ($7500-$8000).
1534...............  New Technology--Level       S            ...........     8,250.00  ...........     1,650.00
                      XXXIV ($8000-$8500).
1535...............  New Technology--Level XXXV  S            ...........     8,750.00  ...........     1,750.00
                      ($8500-$9000).
1536...............  New Technology--Level       S            ...........     9,250.00  ...........     1,850.00
                      XXXVI ($9000-$9500).
1537...............  New Technology--Level       S            ...........     9,750.00  ...........     1,950.00
                      XXXVII ($9500-$10000).
1539...............  New Technology--Level II    T            ...........        75.00  ...........        15.00
                      ($50-$100).
1540...............  New Technology--Level III   T            ...........       150.00  ...........        30.00
                      ($100-$200).
1541...............  New Technology--Level IV    T            ...........       250.00  ...........        50.00
                      ($200-$300).
1542...............  New Technology--Level V     T            ...........       350.00  ...........        70.00
                      ($300-$400).
1543...............  New Technology--Level VI    T            ...........       450.00  ...........        90.00
                      ($400-$500).
1544...............  New Technology--Level VII   T            ...........       550.00  ...........       110.00
                      ($500-$600).
1545...............  New Technology--Level VIII  T            ...........       650.00  ...........       130.00
                      ($600-$700).
1546...............  New Technology--Level IX    T            ...........       750.00  ...........       150.00
                      ($700-$800).
1547...............  New Technology--Level X     T            ...........       850.00  ...........       170.00
                      ($800-$900).
1548...............  New Technology--Level XI    T            ...........       950.00  ...........       190.00
                      ($900-$1000).
1549...............  New Technology--Level XII   T            ...........     1,050.00  ...........       210.00
                      ($1000-$1100).
1550...............  New Technology--Level XIII  T            ...........     1,150.00  ...........       230.00
                      ($1100-$1200).
1551...............  New Technology--Level XIV   T            ...........     1,250.00  ...........       250.00
                      ($1200-$1300).
1552...............  New Technology--Level XV    T            ...........     1,350.00  ...........       270.00
                      ($1300-$1400).
1553...............  New Technology--Level XVI   T            ...........     1,450.00  ...........       290.00
                      ($1400-$1500).
1554...............  New Technology--Level XVII  T            ...........     1,550.00  ...........       310.00
                      ($1500-$1600).
1555...............  New Technology--Level       T            ...........     1,650.00  ...........       330.00
                      XVIII ($1600-$1700).
1556...............  New Technology--Level XIX   T            ...........     1,750.00  ...........       350.00
                      ($1700-$1800).
1557...............  New Technology--Level XX    T            ...........     1,850.00  ...........       370.00
                      ($1800-$1900).
1558...............  New Technology--Level XXI   T            ...........     1,950.00  ...........       390.00
                      ($1900-$2000).
1559...............  New Technology--Level XXII  T            ...........     2,250.00  ...........       450.00
                      ($2000-$2500).
1560...............  New Technology--Level       T            ...........     2,750.00  ...........       550.00
                      XXIII ($2500-$3000).
1561...............  New Technology--Level XXIV  T            ...........     3,250.00  ...........       650.00
                      ($3000-$3500).
1562...............  New Technology--Level XXV   T            ...........     3,750.00  ...........       750.00
                      ($3500-$4000).
1563...............  New Technology--Level XXVI  T            ...........     4,250.00  ...........       850.00
                      ($4000-$4500).
1564...............  New Technology--Level       T            ...........     4,750.00  ...........       950.00
                      XXVII ($4500-$5000).
1565...............  New Technology--Level       T            ...........     5,250.00  ...........     1,050.00
                      XXVIII ($5000-$5500).
1566...............  New Technology--Level XXIX  T            ...........     5,750.00  ...........     1,150.00
                      ($5500-$6000).
1567...............  New Technology--Level XXX   T            ...........     6,250.00  ...........     1,250.00
                      ($6000-$6500).
1568...............  New Technology--Level XXXI  T            ...........     6,750.00  ...........     1,350.00
                      ($6500-$7000).
1569...............  New Technology--Level       T            ...........     7,250.00  ...........     1,450.00
                      XXXII ($7000-$7500).
1570...............  New Technology--Level       T            ...........     7,750.00  ...........     1,550.00
                      XXXIII ($7500-$8000).
1571...............  New Technology--Level       T            ...........     8,250.00  ...........     1,650.00
                      XXXIV ($8000-$8500).
1572...............  New Technology--Level XXXV  T            ...........     8,750.00  ...........     1,750.00
                      ($8500-$9000).
1573...............  New Technology--Level       T            ...........     9,250.00  ...........     1,850.00
                      XXXVI ($9000-$9500).
1574...............  New Technology--Level       T            ...........     9,750.00  ...........     1,950.00
                      XXXVII ($9500-$10000).
1600...............  Tc99m sestamibi...........  H            ...........  ...........  ...........  ...........
1603...............  TL201 thallium............  H            ...........  ...........  ...........  ...........
1604...............  In111 capromab............  H            ...........  ...........  ...........  ...........
1605...............  Abciximab injection.......  K            ...........       416.27  ...........        83.25
1606...............  Injection anistreplase 30   K            ...........     2,268.46  ...........       453.69
                      u.
1607...............  Eptifibatide injection....  K            ...........        15.37  ...........         3.07
1608...............  Etanercept injection......  K            ...........       160.39  ...........        32.08
1609...............  Rho(D) immune globulin h,   K            ...........        14.30  ...........         2.86
                      sd.
1612...............  Daclizumab, parenteral....  K            ...........       328.83  ...........        65.77
1613...............  Trastuzumab...............  K            ...........        56.17  ...........        11.23
1629...............  Nonmetabolic act d/e        K            ...........        18.49  ...........         3.70
                      tissue.
1630...............  Hep b ig, im..............  K            ...........       119.06  ...........        23.81
1631...............  Baclofen intrathecal trial  K            ...........        69.63  ...........        13.93
1632...............  Metabolic active D/E        K            ...........        27.89  ...........         5.58
                      tissue.
1633...............  Alefacept.................  K            ...........        26.31  ...........         5.26
1642...............  In111 ibritumomab, dx.....  H            ...........  ...........  ...........  ...........
1643...............  Y90 ibritumomab, rx.......  H            ...........  ...........  ...........  ...........
1644...............  I131 tositumomab, dx......  H            ...........  ...........  ...........  ...........
1645...............  1131 tositumomab, rx......  H            ...........  ...........  ...........  ...........
1646...............  In111 oxyquinoline........  H            ...........  ...........  ...........  ...........
1647...............  In111 pentetate...........  H            ...........  ...........  ...........  ...........
1648...............  Technetium tc99m            H            ...........  ...........  ...........  ...........
                      arcitumomab.

[[Page 68241]]

 
1650...............  Tc99m succimer............  H            ...........  ...........  ...........  ...........
1651...............  F18 fdg...................  H            ...........  ...........  ...........  ...........
1654...............  Rb82 rubidium.............  H            ...........  ...........  ...........  ...........
1655...............  Tinzaparin sodium           K            ...........         2.48  ...........         0.50
                      injection.
1670...............  Tetanus immune globulin     K            ...........        87.77  ...........        17.55
                      inj.
1671...............  Ga67 gallium..............  H            ...........  ...........  ...........  ...........
1672...............  Tc99m bicisate............  H            ...........  ...........  ...........  ...........
1675...............  P32 Na phosphate..........  H            ...........  ...........  ...........  ...........
1676...............  P32 chromic phosphate.....  H            ...........  ...........  ...........  ...........
1677...............  In111 pentetreotide.......  H            ...........  ...........  ...........  ...........
1678...............  Tc99m fanolesomab.........  H            ...........  ...........  ...........  ...........
1680...............  Acetylcysteine injection..  K            ...........         1.94  ...........         0.39
1682...............  Aprotonin, 10,000 kiu.....  K            ...........         2.52  ...........         0.50
1683...............  Basiliximab...............  K            ...........     1,385.86  ...........       277.17
1684...............  Corticorelin ovine          K            ...........         4.17  ...........         0.83
                      triflutal.
1685...............  Darbepoetin alfa, non-esrd  K            ...........         2.99  ...........         0.60
1686...............  Epoetin alfa, non-esrd....  K            ...........         9.36  ...........         1.87
1687...............  Digoxin immune fab (ovine)  K            ...........       533.72  ...........       106.74
1688...............  Ethanolamine oleate 100 mg  K            ...........        69.60  ...........        13.92
1689...............  Fomepizole, 15 mg.........  K            ...........        12.33  ...........         2.47
1690...............  Hemin, 1 mg...............  K            ...........         6.80  ...........         1.36
1691...............  Iron dextran 165 injection  K            ...........        11.78  ...........         2.36
1692...............  Iron dextran 267 injection  K            ...........        10.38  ...........         2.08
1693...............  Lepirudin.................  K            ...........       153.54  ...........        30.71
1694...............  Ziconotide injection......  G            ...........         6.34  ...........         1.27
1695...............  Nesiritide injection......  K            ...........        30.13  ...........         6.03
1696...............  Palifermin injection......  K            ...........        11.43  ...........         2.29
1697...............  Pegaptanib sodium           G            ...........     1,107.54  ...........       221.51
                      injection.
1700...............  Inj secretin synthetic      K            ...........        20.31  ...........         4.06
                      human.
1701...............  Treprostinil injection....  K            ...........        54.02  ...........        10.80
1703...............  Ovine, 1000 USP units.....  K            ...........       137.43  ...........        27.49
1704...............  Inj Vonwillebrand factor    K            ...........         0.88  ...........         0.18
                      IU.
1705...............  Factor viia...............  K            ...........         1.10  ...........         0.22
1707...............  Non-human, metabolic        K            ...........         1.78  ...........         0.36
                      tissue.
1709...............  Azacitidine injection.....  K            ...........         4.22  ...........         0.84
1710...............  Clofarabine injection.....  G            ...........       116.62  ...........        23.32
1711...............  Histrelin implant.........  K            ...........     1,741.71  ...........       348.34
1712...............  Paclitaxel protein bound..  G            ...........         8.73  ...........         1.75
1713...............  Inj Fe-based MR             K            ...........        30.41  ...........         6.08
                      contrast,1ml.
1716...............  Brachytx source, Gold 198.  K                 0.5991        36.83  ...........         7.37
1717...............  Brachytx source, HDR Ir-    K                 2.3195       142.58  ...........        28.52
                      192.
1718...............  Brachytx source, Iodine     K                 0.5910        36.33  ...........         7.27
                      125.
1719...............  Brachytx sour,Non-HDR Ir-   K                 0.3765        23.14  ...........         4.63
                      192.
1720...............  Brachytx sour, Palladium    K                 0.7942        48.82  ...........         9.76
                      103.
1738...............  Oxaliplatin...............  K            ...........         8.77  ...........         1.75
1739...............  Pegademase bovine, 25 iu..  K            ...........       177.83  ...........        35.57
1740...............  Diazoxide injection.......  K            ...........       111.89  ...........        22.38
1741...............  Urofollitropin, 75 iu.....  K            ...........        49.35  ...........         9.87
1820...............  Generator neuro rechg bat   H            ...........  ...........  ...........  ...........
                      sys.
1821...............  Interspinous implant......  H            ...........  ...........  ...........  ...........
2210...............  Methyldopate hcl injection  K            ...........        10.01  ...........         2.00
2616...............  Brachytx source, Yttrium-   K               172.2337    10,586.86  ...........     2,117.37
                      90.
2632...............  Iodine I-125 sodium iodide  K                 0.3321        20.41  ...........         4.08
2633...............  Brachytx source, Cesium-    K                 1.4779        90.84  ...........        18.17
                      131.
2634...............  Brachytx source, HA, I-125  K                 0.5316        32.68  ...........         6.54
2635...............  Brachytx source, HA, P-103  K                 0.8878        54.57  ...........        10.91
2636...............  Brachytx linear source,P-   K                 0.6427        39.51  ...........         7.90
                      103.
2731...............  Immune globulin, powder...  K            ...........        25.27  ...........         5.05
2732...............  Immune globulin, liquid...  K            ...........        30.33  ...........         6.07
2770...............  Quinupristin/dalfopristin.  K            ...........       114.49  ...........        22.90
2940...............  Somatrem injection........  K            ...........        35.60  ...........         7.12
3030...............  Sumatriptan succinate / 6   K            ...........        57.40  ...........        11.48
                      MG.
3032...............  Dtp/hib vaccine, im.......  K            ...........        45.01  ...........         9.00
3038...............  Inj biperiden lactate/5 mg  K            ...........        88.15  ...........        17.63
3039...............  Inj metaraminol bitartrate  K            ...........         2.62  ...........         0.52
3041...............  Bivalirudin...............  K            ...........         1.75  ...........         0.35
3042...............  Foscarnet sodium injection  K            ...........        10.49  ...........         2.10
3043...............  Gamma globulin 1 CC inj...  K            ...........        10.34  ...........         2.07
3045...............  Meropenem.................  K            ...........         3.68  ...........         0.74

[[Page 68242]]

 
3048...............  Doxorubic hcl 10 MG vl      K            ...........         6.00  ...........         1.20
                      chemo.
3049...............  Cyclophosphamide            K            ...........         5.72  ...........         1.14
                      lyophilized.
3050...............  Sermorelin acetate          K            ...........         1.75  ...........         0.35
                      injection.
7000...............  Amifostine................  K            ...........       463.27  ...........        92.65
7005...............  Gonadorelin hydroch/ 100    K            ...........       189.84  ...........        37.97
                      mcg.
7011...............  Oprelvekin injection......  K            ...........       245.98  ...........        49.20
7015...............  Oral busulfan.............  K            ...........         2.14  ...........         0.43
7028...............  Fosphenytoin, 50 mg.......  K            ...........         5.59  ...........         1.12
7034...............  Somatropin injection......  K            ...........        46.80  ...........         9.36
7035...............  Teniposide, 50 mg.........  K            ...........       264.88  ...........        52.98
7036...............  Urokinase 250,000 IU inj..  K            ...........       457.73  ...........        91.55
7038...............  Monoclonal antibodies.....  K            ...........       856.05  ...........       171.21
7041...............  Tirofiban HCl.............  K            ...........         8.74  ...........         1.75
7042...............  Capecitabine, oral, 150 mg  K            ...........         3.83  ...........         0.77
7043...............  Infliximab injection......  K            ...........        53.74  ...........        10.75
7045...............  Inj trimetrexate            K            ...........       145.17  ...........        29.03
                      glucoronate.
7046...............  Doxorubicin hcl liposome    K            ...........       379.21  ...........        75.84
                      inj.
7048...............  Alteplase recombinant.....  K            ...........        32.07  ...........         6.41
7049...............  Filgrastim 480 mcg          K            ...........       298.70  ...........        59.74
                      injection.
7051...............  Leuprolide acetate implant  K            ...........     2,208.90  ...........       441.78
7308...............  Aminolevulinic acid hcl     K            ...........       107.72  ...........        21.54
                      top.
9001...............  Linezolid injection.......  K            ...........        24.16  ...........         4.83
9002...............  Tenecteplase injection....  K            ...........     2,036.66  ...........       407.33
9003...............  Palivizumab, per 50 mg....  K            ...........       609.62  ...........       121.92
9004...............  Gemtuzumab ozogamicin.....  K            ...........     2,317.16  ...........       463.43
9005...............  Reteplase injection.......  K            ...........       902.72  ...........       180.54
9006...............  Tacrolimus injection......  K            ...........       140.72  ...........        28.14
9012...............  Arsenic trioxide..........  K            ...........        33.36  ...........         6.67
9015...............  Mycophenolate mofetil oral  K            ...........         2.50  ...........         0.50
9018...............  Botulinum toxin type B....  K            ...........         8.16  ...........         1.63
9019...............  Caspofungin acetate.......  K            ...........        32.25  ...........         6.45
9020...............  Sirolimus, oral...........  K            ...........         7.25  ...........         1.45
9022...............  IM inj interferon beta 1-a  K            ...........       108.04  ...........        21.61
9023...............  Rho d immune globulin 50    K            ...........        27.70  ...........         5.54
                      mcg.
9024...............  Amphotericin b lipid        K            ...........        11.11  ...........         2.22
                      complex.
9031...............  Arbutamine HCl injection..  K            ...........       160.00  ...........        32.00
9032...............  Baclofen 10 MG injection..  K            ...........       198.54  ...........        39.71
9033...............  Cidofovir injection.......  K            ...........       763.15  ...........       152.63
9038...............  Inj estrogen conjugate 25   K            ...........        58.05  ...........        11.61
                      MG.
9040...............  Intraocular Fomivirsen na.  K            ...........       212.00  ...........        42.40
9042...............  Glucagon hydrochloride/1    K            ...........        70.23  ...........        14.05
                      MG.
9044...............  Ibutilide fumarate          K            ...........       265.75  ...........        53.15
                      injection.
9046...............  Iron sucrose injection....  K            ...........         0.36  ...........         0.07
9047...............  Itraconazole injection....  K            ...........        36.45  ...........         7.29
9051...............  Urea injection............  K            ...........        37.81  ...........         7.56
9054...............  Metabolically active        K            ...........        13.87  ...........         2.77
                      tissue.
9100...............  I131 serum albumin, dx....  H            ...........  ...........  ...........  ...........
9104...............  Antithymocyte globuln       K            ...........       329.62  ...........        65.92
                      rabbit.
9108...............  Thyrotropin injection.....  K            ...........       765.76  ...........       153.15
9110...............  Alemtuzumab injection.....  K            ...........       531.24  ...........       106.25
9112...............  Inj perflutren lip          K            ...........        61.64  ...........        12.33
                      micros,ml.
9115...............  Zoledronic acid...........  K            ...........       204.03  ...........        40.81
9119...............  Injection, pegfilgrastim    K            ...........     2,163.61  ...........       432.72
                      6mg.
9120...............  Injection, Fulvestrant....  K            ...........        80.66  ...........        16.13
9121...............  Injection, argatroban.....  K            ...........        17.48  ...........         3.50
9122...............  Triptorelin pamoate.......  K            ...........       218.53  ...........        43.71
9124...............  Daptomycin injection......  K            ...........         0.33  ...........         0.07
9125...............  Risperidone, long acting..  K            ...........         4.80  ...........         0.96
9126...............  Natalizumab injection.....  G            ...........         7.72  ...........         1.54
9133...............  Rabies ig, im/sc..........  K            ...........        64.53  ...........        12.91
9134...............  Rabies ig, heat treated...  K            ...........        68.24  ...........        13.65
9135...............  Varicella-zoster ig, im...  K            ...........       140.92  ...........        28.18
9137...............  Bcg vaccine, percut.......  K            ...........       117.39  ...........        23.48
9139...............  Rabies vaccine, im........  K            ...........       157.74  ...........        31.55
9140...............  Rabies vaccine, id........  K            ...........       166.16  ...........        33.23
9141...............  Measles-rubella vaccine,    K            ...........        60.82  ...........        12.16
                      sc.
9143...............  Meningococcal vaccine, sc.  K            ...........        84.46  ...........        16.89
9144...............  Encephalitis vaccine, sc..  K            ...........        96.22  ...........        19.24
9145...............  Meningococcal vaccine, im.  K            ...........        53.71  ...........        10.74

[[Page 68243]]

 
9148...............  I123 iodide cap, dx.......  H            ...........  ...........  ...........  ...........
9156...............  Nonmetabolic active tissue  K            ...........        45.02  ...........         9.00
9157...............  LOCM <=149 mg/ml iodine,    K            ...........         0.29  ...........         0.06
                      1ml.
9158...............  LOCM 150-199mg/ml           K            ...........         1.96  ...........         0.39
                      iodine,1ml.
9159...............  LOCM 200-249mg/ml           K            ...........         1.42  ...........         0.28
                      iodine,1ml.
9160...............  LOCM 250-299mg/ml           K            ...........         0.27  ...........         0.05
                      iodine,1ml.
9161...............  LOCM 300-349mg/ml           K            ...........         0.35  ...........         0.07
                      iodine,1ml.
9162...............  LOCM 350-399mg/ml           K            ...........         0.21  ...........         0.04
                      iodine,1ml.
9163...............  LOCM >= 400 mg/ml           K            ...........         0.30  ...........         0.06
                      iodine,1ml.
9164...............  Inj Gad-base MR             K            ...........         2.87  ...........         0.57
                      contrast,1ml.
9165...............  Oral MR contrast, 100 ml..  K            ...........         8.90  ...........         1.78
9167...............  Valrubicin, 200 mg........  K            ...........       369.60  ...........        73.92
9202...............  Inj octafluoropropane       K            ...........        49.61  ...........         9.92
                      mic,ml.
9203...............  Inj perflexane lip          K            ...........         7.05  ...........         1.41
                      micros,ml.
9207...............  Bortezomib injection......  K            ...........        31.87  ...........         6.37
9208...............  Agalsidase beta injection.  K            ...........       127.20  ...........        25.44
9209...............  Laronidase injection......  K            ...........        23.87  ...........         4.77
9210...............  Palonosetron HCl..........  K            ...........        18.08  ...........         3.62
9213...............  Pemetrexed injection......  K            ...........        42.49  ...........         8.50
9214...............  Bevacizumab injection.....  K            ...........        56.88  ...........        11.38
9215...............  Cetuximab injection.......  K            ...........        49.86  ...........         9.97
9216...............  Abarelix injection........  K            ...........        71.18  ...........        14.24
9217...............  Leuprolide acetate          K            ...........       227.63  ...........        45.53
                      suspnsion.
9219...............  Mycophenolic acid.........  K            ...........         2.15  ...........         0.43
9222...............  Injectable human tissue...  K            ...........       743.96  ...........       148.79
9224...............  Galsulfase injection......  K            ...........     1,516.12  ...........       303.22
9225...............  Fluocinolone acetonide      G            ...........    18,250.00  ...........     3,650.00
                      implt.
9227...............  Micafungin sodium           G            ...........         1.87  ...........         0.37
                      injection.
9228...............  Tigecycline injection.....  G            ...........         0.91  ...........         0.18
9229...............  Ibandronate sodium          G            ...........       139.12  ...........        27.82
                      injection.
9230...............  Abatacept injection.......  G            ...........        18.70  ...........         3.74
9231...............  Decitabine injection......  G            ...........        26.50  ...........         5.30
9232...............  Injection, idursulfase....  G            ...........       464.32  ...........        92.86
9233...............  Injection, ranibizumab....  G            ...........     2,067.00  ...........       413.40
9234...............  Inj, alglucosidase alfa...  K            ...........       127.20  ...........        25.44
9235...............  Injection, panitumumab....  K            ...........        84.80  ...........        16.96
9300...............  Omalizumab injection......  K            ...........        16.61  ...........         3.32
9350...............  Porous collagen tube per    G            ...........       494.53  ...........        98.91
                      cm.
9351...............  Acellular derm tissue       G            ...........        44.01  ...........         8.80
                      percm2.
9500...............  Platelets, irradiated.....  K                 2.1079       129.57  ...........        25.91
9501...............  Platelet pheres             K                 7.9511       488.74  ...........        97.75
                      leukoreduced.
9502...............  Platelet pheresis           K                 6.8088       418.52  ...........        83.70
                      irradiated.
9503...............  Fr frz plasma donor         K                 1.2119        74.49  ...........        14.90
                      retested.
9504...............  RBC deglycerolized........  K                 5.8292       358.31  ...........        71.66
9505...............  RBC irradiated............  K                 3.2049       197.00  ...........        39.40
9506...............  Granulocytes, pheresis      K                12.2073       750.36  ...........       150.07
                      unit.
9507...............  Platelets, pheresis.......  K                 7.3686       452.93  ...........        90.59
9508...............  Plasma 1 donor frz w/in 8   K                 1.1422        70.21  ...........        14.04
                      hr.
----------------------------------------------------------------------------------------------------------------


 Addendum AA.--List of Medicare Approved ASC Procedures for CY 2007 With Additions and Payment Rates, Including
           Rates That Result From Implementation of Section 5103 of the Deficit Reduction Act of 2005
----------------------------------------------------------------------------------------------------------------
                                  A*=new to
                                  list; 2007       OPPS         ASC          ASC                         ASC
    HCPCS           Short        CPT Changes:    payment      payment      payment       DRA cap      copayment
                  descriptor        A=Add        rate ($)      group       rate ($)                   amount ($)
                                   D=Delete
----------------------------------------------------------------------------------------------------------------
10121........  Remove foreign   .............       928.31            2       446.00  .............        89.20
                body.
10180........  Complex          .............     1,076.22            2       446.00  .............        89.20
                drainage,
                wound.
11010........  Debride skin,    .............       251.52            2       251.52  Y............        50.30
                fx.
11011........  Debride skin/    .............       251.52            2       251.52  Y............        50.30
                muscle, fx.
11012........  Debride skin/    .............       251.52            2       251.52  Y............        50.30
                muscle/bone,
                fx.
11042........  Debride skin/    .............       164.42            2       164.42  Y............        32.88
                tissue.
11043........  Debride tissue/  .............       164.42            2       164.42  Y............        32.88
                muscle.
11044........  Debride tissue/  .............       423.10            2       423.10  Y............        84.62
                muscle/bone.

[[Page 68244]]

 
11404........  Exc tr-ext       .............       928.31            1       333.00  .............        66.60
                b9+marg 3.1-4
                cm.
11406........  Exc tr-ext       .............       928.31            2       446.00  .............        89.20
                b9+marg > 4.0
                cm.
11424........  Exc h-f-nk-sp    .............       928.31            2       446.00  .............        89.20
                b9+marg 3.1-4.
11426........  Exc h-f-nk-sp    .............     1,233.39            2       446.00  .............        89.20
                b9+marg > 4 cm.
11444........  Exc face-mm      .............       418.49            1       333.00  .............        66.60
                b9+marg 3.1-4
                cm.
11446........  Exc face-mm      .............     1,233.39            2       446.00  .............        89.20
                b9+marg > 4 cm.
11450........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11451........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11462........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11463........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11470........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11471........  Removal, sweat   .............     1,233.39            2       446.00  .............        89.20
                gland lesion.
11604........  Exc tr-ext       .............       418.49            2       418.49  Y............        83.70
                mlg+marg 3.1-4
                cm.
11606........  Exc tr-ext       .............       928.31            2       446.00  .............        89.20
                mlg+marg > 4
                cm.
11624........  Exc h-f-nk-sp    .............       928.31            2       446.00  .............        89.20
                mlg+marg 3.1-4.
11626........  Exc h-f-nk-sp    .............     1,233.39            2       446.00  .............        89.20
                mlg+mar > 4 cm.
11644........  Exc face-mm      .............       928.31            2       446.00  .............        89.20
                malig+marg 3.1-
                4.
11646........  Exc face-mm      .............     1,233.39            2       446.00  .............        89.20
                mlg+marg > 4
                cm.
11770........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                pilonidal
                lesion.
11771........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                pilonidal
                lesion.
11772........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                pilonidal
                lesion.
11960........  Insert tissue    .............     1,317.27            2       446.00  .............        89.20
                expander(s).
11970........  Replace tissue   .............     2,525.68            3       510.00  .............       102.00
                expander.
11971........  Remove tissue    .............     1,233.39            1       333.00  .............        66.60
                expander(s).
12005........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12006........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12007........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12016........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12017........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12018........  Repair           .............        91.24            2        91.24  Y............        18.25
                superficial
                wound(s).
12020........  Closure of       .............        91.24            1        91.24  Y............        18.25
                split wound.
12021........  Closure of       .............        91.24            1        91.24  Y............        18.25
                split wound.
12034........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12035........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12036........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12037........  Layer closure    .............       323.28            2       323.28  Y............        64.66
                of wound(s).
12044........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12045........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12046........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12047........  Layer closure    .............       323.28            2       323.28  Y............        64.66
                of wound(s).
12054........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12055........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12056........  Layer closure    .............        91.24            2        91.24  Y............        18.25
                of wound(s).
12057........  Layer closure    .............       323.28            2       323.28  Y............        64.66
                of wound(s).
13100........  Repair of wound  .............       323.28            2       323.28  Y............        64.66
                or lesion.
13101........  Repair of wound  .............       323.28            3       323.28  Y............        64.66
                or lesion.
13102........  Repair wound/    A*...........        91.24            1        91.24  Y............        18.25
                lesion add-on.
13120........  Repair of wound  .............        91.24            2        91.24  Y............        18.25
                or lesion.
13121........  Repair of wound  .............        91.24            3        91.24  Y............        18.25
                or lesion.
13122........  Repair wound/    A*...........        91.24            1        91.24  Y............        18.25
                lesion add-on.
13131........  Repair of wound  .............        91.24            2        91.24  Y............        18.25
                or lesion.
13132........  Repair of wound  .............        91.24            3        91.24  Y............        18.25
                or lesion.
13133........  Repair wound/    A*...........        91.24            1        91.24  Y............        18.25
                lesion add-on.
13150........  Repair of wound  .............       323.28            3       323.28  Y............        64.66
                or lesion.
13151........  Repair of wound  .............       323.28            3       323.28  Y............        64.66
                or lesion.
13152........  Repair of wound  .............       323.28            3       323.28  Y............        64.66
                or lesion.
13153........  Repair wound/    A*...........        91.24            3        91.24  Y............        18.25
                lesion add-on.
13160........  Late closure of  .............     1,317.27            2       446.00  .............        89.20
                wound.
14000........  Skin tissue      .............       862.68            2       446.00  .............        89.20
                rearrangement.
14001........  Skin tissue      .............     1,317.27            3       510.00  .............       102.00
                rearrangement.
14020........  Skin tissue      .............       862.68            3       510.00  .............       102.00
                rearrangement.
14021........  Skin tissue      .............       862.68            3       510.00  .............       102.00
                rearrangement.
14040........  Skin tissue      .............       862.68            2       446.00  .............        89.20
                rearrangement.
14041........  Skin tissue      .............       862.68            3       510.00  .............       102.00
                rearrangement.
14060........  Skin tissue      .............       862.68            3       510.00  .............       102.00
                rearrangement.

[[Page 68245]]

 
14061........  Skin tissue      .............       862.68            3       510.00  .............       102.00
                rearrangement.
14300........  Skin tissue      .............     1,317.27            4       630.00  .............       126.00
                rearrangement.
14350........  Skin tissue      .............     1,317.27            3       510.00  .............       102.00
                rearrangement.
15000........  Wound prep, 1st  D............  ...........            2       446.00  .............  ...........
                100 sq cm.
15001........  Wound prep,      D............  ...........            1       333.00  .............  ...........
                addl 100 sq cm.
15002........  Wnd prep, ch/    A............       323.28            2       323.28  Y............        64.66
                inf, trk/arm/
                lg.
15003........  Wnd prep, ch/    A............       323.28            1       323.28  Y............        64.66
                inf addl 100
                cm.
15004........  Wnd prep ch/     A............       323.28            2       323.28  Y............        64.66
                inf, f/n/hf/g.
15005........  Wnd prep, f/n/   A............       323.28            1       323.28  Y............        64.66
                hf/g, addl cm.
15040........  Harvest          .............        91.24            2        91.24  Y............        18.25
                cultured skin
                graft.
15050........  Skin pinch       .............       323.28            2       323.28  Y............        64.66
                graft.
15100........  Skin splt grft,  .............     1,317.27            2       446.00  .............        89.20
                trnk/arm/leg.
15101........  Skin splt grft   .............     1,317.27            3       510.00  .............       102.00
                t/a/l, add-on.
15110........  Epidrm autogrft  .............     1,317.27            2       446.00  .............        89.20
                trnk/arm/leg.
15111........  Epidrm autogrft  .............     1,317.27            1       333.00  .............        66.60
                t/a/l add-on.
15115........  Epidrm a-grft    .............     1,317.27            2       446.00  .............        89.20
                face/nck/hf/g.
15116........  Epidrm a-grft f/ .............     1,317.27            1       333.00  .............        66.60
                n/hf/g addl.
15120........  Skn splt a-grft  .............     1,317.27            2       446.00  .............        89.20
                fac/nck/hf/g.
15121........  Skn splt a-grft  .............     1,317.27            3       510.00  .............       102.00
                f/n/hf/g add.
15130........  Derm autograft,  .............     1,317.27            2       446.00  .............        89.20
                trnk/arm/leg.
15131........  Derm autograft   .............     1,317.27            1       333.00  .............        66.60
                t/a/l add-on.
15135........  Derm autograft   .............     1,317.27            2       446.00  .............        89.20
                face/nck/hf/g.
15136........  Derm autograft,  .............     1,317.27            1       333.00  .............        66.60
                f/n/hf/g add.
15150........  Cult epiderm     .............     1,317.27            2       446.00  .............        89.20
                grft t/arm/leg.
15151........  Cult epiderm     .............     1,317.27            1       333.00  .............        66.60
                grft t/a/l
                addl.
15152........  Cult epiderm     .............     1,317.27            1       333.00  .............        66.60
                graft t/a/l +%.
15155........  Cult epiderm     .............     1,317.27            2       446.00  .............        89.20
                graft, f/n/hf/
                g.
15156........  Cult epidrm      .............     1,317.27            1       333.00  .............        66.60
                grft f/n/hfg
                add.
15157........  Cult epiderm     .............     1,317.27            1       333.00  .............        66.60
                grft f/n/hfg
                +%.
15200........  Skin full        .............       862.68            3       510.00  .............       102.00
                graft, trunk.
15201........  Skin full graft  .............       323.28            2       323.28  Y............        64.66
                trunk add-on.
15220........  Skin full graft  .............       862.68            2       446.00  .............        89.20
                sclp/arm/leg.
15221........  Skin full graft  .............       323.28            2       323.28  Y............        64.66
                add-on.
15240........  Skin full grft   .............       862.68            3       510.00  .............       102.00
                face/genit/hf.
15241........  Skin full graft  .............       323.28            3       323.28  Y............        64.66
                add-on.
15260........  Skin full graft  .............       862.68            2       446.00  .............        89.20
                een & lips.
15261........  Skin full graft  .............       323.28            2       323.28  Y............        64.66
                add-on.
15300........  Apply            .............       323.28            2       323.28  Y............        64.66
                skinallogrft,
                t/arm/lg.
15301........  Apply            .............       323.28            1       323.28  Y............        64.66
                sknallogrft t/
                a/l addl.
15320........  Apply skin       .............       323.28            2       323.28  Y............        64.66
                allogrft f/n/
                hf/g.
15321........  Aply             .............       323.28            1       323.28  Y............        64.66
                sknallogrft f/
                n/hfg add.
15330........  Aply acell       .............       323.28            2       323.28  Y............        64.66
                alogrft t/arm/
                leg.
15331........  Aply acell grft  .............       323.28            1       323.28  Y............        64.66
                t/a/l add-on.
15335........  Apply acell      .............       323.28            2       323.28  Y............        64.66
                graft, f/n/hf/
                g.
15336........  Aply acell grft  .............       323.28            1       323.28  Y............        64.66
                f/n/hf/g add.
15400........  Apply skin       .............       323.28            2       323.28  Y............        64.66
                xenograft, t/a/
                l.
15401........  Apply skn        .............       323.28            2       323.28  Y............        64.66
                xenogrft t/a/l
                add.
15420........  Apply skin       .............       323.28            2       323.28  Y............        64.66
                xgraft, f/n/hf/
                g.
15421........  Apply skn xgrft  .............       323.28            1       323.28  Y............        64.66
                f/n/hf/g add.
15430........  Apply acellular  .............       323.28            2       323.28  Y............        64.66
                xenograft.
15431........  Apply acellular  .............       323.28            1       323.28  Y............        64.66
                xgraft add.
15570........  Form skin        .............     1,317.27            3       510.00  .............       102.00
                pedicle flap.
15572........  Form skin        .............     1,317.27            3       510.00  .............       102.00
                pedicle flap.
15574........  Form skin        .............     1,317.27            3       510.00  .............       102.00
                pedicle flap.
15576........  Form skin        .............       862.68            3       510.00  .............       102.00
                pedicle flap.
15600........  Skin graft.....  .............     1,317.27            3       510.00  .............       102.00
15610........  Skin graft.....  .............     1,317.27            3       510.00  .............       102.00
15620........  Skin graft.....  .............     1,317.27            4       630.00  .............       126.00
15630........  Skin graft.....  .............     1,317.27            3       510.00  .............       102.00
15650........  Transfer skin    .............     1,317.27            5       717.00  .............       143.40
                pedicle flap.
15731........  Forehead flap w/ A............       862.68            3       510.00  .............       102.00
                vasc pedicle.
15732........  Muscle-skin      .............     1,317.27            3       510.00  .............       102.00
                graft, head/
                neck.
15734........  Muscle-skin      .............     1,317.27            3       510.00  .............       102.00
                graft, trunk.
15736........  Muscle-skin      .............     1,317.27            3       510.00  .............       102.00
                graft, arm.
15738........  Muscle-skin      .............     1,317.27            3       510.00  .............       102.00
                graft, leg.

[[Page 68246]]

 
15740........  Island pedicle   .............       862.68            2       446.00  .............        89.20
                flap graft.
15750........  Neurovascular    .............     1,317.27            2       446.00  .............        89.20
                pedicle graft.
15760........  Composite skin   .............     1,317.27            2       446.00  .............        89.20
                graft.
15770........  Derma-fat-       .............     1,317.27            3       510.00  .............       102.00
                fascia graft.
15775........  Hair transplant  .............       323.28            3       323.28  Y............        64.66
                punch grafts.
15776........  Hair transplant  .............       323.28            3       323.28  Y............        64.66
                punch grafts.
15820........  Revision of      .............     1,317.27            3       510.00  .............       102.00
                lower eyelid.
15821........  Revision of      .............     1,317.27            3       510.00  .............       102.00
                lower eyelid.
15822........  Revision of      .............     1,317.27            3       510.00  .............       102.00
                upper eyelid.
15823........  Revision of      .............       862.68            5       717.00  .............       143.40
                upper eyelid.
15824........  Removal of       .............     1,317.27            3       510.00  .............       102.00
                forehead
                wrinkles.
15825........  Removal of neck  .............     1,317.27            3       510.00  .............       102.00
                wrinkles.
15826........  Removal of brow  .............     1,317.27            3       510.00  .............       102.00
                wrinkles.
15828........  Removal of face  .............     1,317.27            3       510.00  .............       102.00
                wrinkles.
15829........  Removal of skin  .............     1,317.27            5       717.00  .............       143.40
                wrinkles.
15830........  Exc skin abd...  A............     1,233.39            3       510.00  .............       102.00
15831........  Excise           D............  ...........            3       510.00  .............  ...........
                excessive skin
                tissue.
15832........  Excise           .............     1,233.39            3       510.00  .............       102.00
                excessive skin
                tissue.
15833........  Excise           .............     1,233.39            3       510.00  .............       102.00
                excessive skin
                tissue.
15834........  Excise           .............     1,233.39            3       510.00  .............       102.00
                excessive skin
                tissue.
15835........  Excise           .............       323.28            3       323.28  Y............        64.66
                excessive skin
                tissue.
15836........  Excise           .............       928.31            3       510.00  .............       102.00
                excessive skin
                tissue.
15839........  Excise           .............       928.31            3       510.00  .............       102.00
                excessive skin
                tissue.
15840........  Graft for face   .............     1,317.27            4       630.00  .............       126.00
                nerve palsy.
15841........  Graft for face   .............     1,317.27            4       630.00  .............       126.00
                nerve palsy.
15845........  Skin and muscle  .............     1,317.27            4       630.00  .............       126.00
                repair, face.
15847........  Exc skin abd     A............     1,233.39            3       510.00  .............       102.00
                add-on.
15876........  Suction          .............     1,317.27            3       510.00  .............       102.00
                assisted
                lipectomy.
15877........  Suction          .............     1,317.27            3       510.00  .............       102.00
                assisted
                lipectomy.
15878........  Suction          .............       862.68            3       510.00  .............       102.00
                assisted
                lipectomy.
15879........  Suction          .............     1,317.27            3       510.00  .............       102.00
                assisted
                lipectomy.
15920........  Removal of tail  .............       251.52            3       251.52  Y............        50.30
                bone ulcer.
15922........  Removal of tail  .............     1,317.27            4       630.00  .............       126.00
                bone ulcer.
15931........  Remove sacrum    .............     1,233.39            3       510.00  .............       102.00
                pressure sore.
15933........  Remove sacrum    .............     1,233.39            3       510.00  .............       102.00
                pressure sore.
15934........  Remove sacrum    .............     1,317.27            3       510.00  .............       102.00
                pressure sore.
15935........  Remove sacrum    .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15936........  Remove sacrum    .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15937........  Remove sacrum    .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15940........  Remove hip       .............     1,233.39            3       510.00  .............       102.00
                pressure sore.
15941........  Remove hip       .............     1,233.39            3       510.00  .............       102.00
                pressure sore.
15944........  Remove hip       .............     1,317.27            3       510.00  .............       102.00
                pressure sore.
15945........  Remove hip       .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15946........  Remove hip       .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15950........  Remove thigh     .............     1,233.39            3       510.00  .............       102.00
                pressure sore.
15951........  Remove thigh     .............     1,233.39            4       630.00  .............       126.00
                pressure sore.
15952........  Remove thigh     .............     1,317.27            3       510.00  .............       102.00
                pressure sore.
15953........  Remove thigh     .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
15956........  Remove thigh     .............     1,317.27            3       510.00  .............       102.00
                pressure sore.
15958........  Remove thigh     .............     1,317.27            4       630.00  .............       126.00
                pressure sore.
16025........  Dress/debrid p-  .............        67.11            2        67.11  Y............        13.42
                thick burn, m.
16030........  Dress/debrid p-  .............        99.83            2        99.83  Y............        19.97
                thick burn, l.
19020........  Incision of      .............     1,076.22            2       446.00  .............        89.20
                breast lesion.
19100........  Bx breast        .............       240.00            1       240.00  Y............        48.00
                percut w/o
                image.
19101........  Biopsy of        .............     1,185.03            2       446.00  .............        89.20
                breast, open.
19102........  Bx breast        .............       240.00            2       240.00  Y............        48.00
                percut w/image.
19103........  Bx breast        .............       395.77            2       395.77  Y............        79.15
                percut w/
                device.
19110........  Nipple           .............     1,185.03            2       446.00  .............        89.20
                exploration.
19112........  Excise breast    .............     1,185.03            3       510.00  .............       102.00
                duct fistula.
19120........  Removal of       .............     1,185.03            3       510.00  .............       102.00
                breast lesion.
19125........  Excision,        .............     1,185.03            3       510.00  .............       102.00
                breast lesion.
19126........  Excision, addl   .............     1,185.03            3       510.00  .............       102.00
                breast lesion.
19140........  Removal of       D............  ...........            4       630.00  .............  ...........
                breast tissue.
19160........  Partial          D............  ...........            3       510.00  .............  ...........
                mastectomy.
19162........  P-mastectomy w/  D............  ...........            7       995.00  .............  ...........
                ln removal.

[[Page 68247]]

 
19180........  Removal of       D............  ...........            4       630.00  .............  ...........
                breast.
19182........  Removal of       D............  ...........            4       630.00  .............  ...........
                breast.
19290........  Place needle     .............  ...........            1       333.00  .............        66.60
                wire, breast.
19291........  Place needle     .............  ...........            1       333.00  .............        66.60
                wire, breast.
19295........  Place breast     A*...........       106.76            1       106.76  Y............        21.35
                clip, percut.
19296........  Place po breast  .............     3,148.82            9     1,339.00  .............       267.80
                cath for rad.
19297........  Place breast     A*...........     3,148.82            9     1,339.00  .............       267.80
                cath for rad.
19298........  Place breast     .............     3,250.00            9     1,339.00  .............       267.80
                rad tube/caths.
19300........  Removal of       A............     1,185.03            4       630.00  .............       126.00
                breast tissue.
19301........  Partical         A............     1,185.03            3       510.00  .............       102.00
                mastectomy.
19302........  P-mastectomy w/  A............     2,274.24            7       995.00  .............       199.00
                ln removal.
19303........  Mast, simple,    A............     1,722.12            4       630.00  .............       126.00
                complete.
19304........  Mast, subq.....  A............     1,722.12            4       630.00  .............       126.00
19316........  Suspension of    .............     1,722.12            4       630.00  .............       126.00
                breast.
19318........  Reduction of     .............     2,274.24            4       630.00  .............       126.00
                large breast.
19324........  Enlarge breast.  .............     2,274.24            4       630.00  .............       126.00
19325........  Enlarge breast   .............     3,148.82            9     1,339.00  .............       267.80
                with implant.
19328........  Removal of       .............     1,722.12            1       333.00  .............        66.60
                breast implant.
19330........  Removal of       .............     1,722.12            1       333.00  .............        66.60
                implant
                material.
19340........  Immediate        .............     2,327.74            2       446.00  .............        89.20
                breast
                prosthesis.
19342........  Delayed breast   .............     3,148.82            3       510.00  .............       102.00
                prosthesis.
19350........  Breast           .............     1,185.03            4       630.00  .............       126.00
                reconstruction.
19355........  Correct          .............     1,722.12            4       630.00  .............       126.00
                inverted
                nipple(s).
19357........  Breast           .............     3,148.82            5       717.00  .............       143.40
                reconstruction.
19366........  Breast           .............     1,722.12            5       717.00  .............       143.40
                reconstruction.
19370........  Surgery of       .............     1,722.12            4       630.00  .............       126.00
                breast capsule.
19371........  Removal of       .............     1,722.12            4       630.00  .............       126.00
                breast capsule.
19380........  Revise breast    .............     2,327.74            5       717.00  .............       143.40
                reconstruction.
20005........  Incision of      .............     1,282.87            2       446.00  .............        89.20
                deep abscess.
20200........  Muscle biopsy..  .............       928.31            2       446.00  .............        89.20
20205........  Deep muscle      .............       928.31            3       510.00  .............       102.00
                biopsy.
20206........  Needle biopsy,   .............       240.00            1       240.00  Y............        48.00
                muscle.
20220........  Bone biopsy,     .............       251.52            1       251.52  Y............        50.30
                trocar/needle.
20225........  Bone biopsy,     .............       418.49            2       418.49  Y............        83.70
                trocar/needle.
20240........  Bone biopsy,     .............     1,233.39            2       446.00  .............        89.20
                excisional.
20245........  Bone biopsy,     .............     1,233.39            3       510.00  .............       102.00
                excisional.
20250........  Open bone        .............     1,282.87            3       510.00  .............       102.00
                biopsy.
20251........  Open bone        .............     1,282.87            3       510.00  .............       102.00
                biopsy.
20525........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                foreign body.
20650........  Insert and       .............     1,282.87            3       510.00  .............       102.00
                remove bone
                pin.
20670........  Removal of       .............       928.31            1       333.00  .............        66.60
                support
                implant.
20680........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                support
                implant.
20690........  Apply bone       .............     1,544.67            2       446.00  .............        89.20
                fixation
                device.
20692........  Apply bone       .............     1,544.67            3       510.00  .............       102.00
                fixation
                device.
20693........  Adjust bone      .............     1,282.87            3       510.00  .............       102.00
                fixation
                device.
20694........  Remove bone      .............     1,282.87            1       333.00  .............        66.60
                fixation
                device.
20900........  Removal of bone  .............     1,544.67            3       510.00  .............       102.00
                for graft.
20902........  Removal of bone  .............     1,544.67            4       630.00  .............       126.00
                for graft.
20910........  Remove           .............     1,317.27            3       510.00  .............       102.00
                cartilage for
                graft.
20912........  Remove           .............     1,317.27            3       510.00  .............       102.00
                cartilage for
                graft.
20920........  Removal of       .............       862.68            4       630.00  .............       126.00
                fascia for
                graft.
20922........  Removal of       .............     1,317.27            3       510.00  .............       102.00
                fascia for
                graft.
20924........  Removal of       .............     1,544.67            4       630.00  .............       126.00
                tendon for
                graft.
20926........  Removal of       .............       862.68            4       630.00  .............       126.00
                tissue for
                graft.
20975........  Electrical bone  .............        37.51            2        37.51  Y............         7.50
                stimulation.
21010........  Incision of jaw  .............     1,434.04            2       446.00  .............        89.20
                joint.
21015........  Resection of     .............     1,009.71            3       510.00  .............       102.00
                facial tumor.
21025........  Excision of      .............     2,348.02            2       446.00  .............        89.20
                bone, lower
                jaw.
21026........  Excision of      .............     2,348.02            2       446.00  .............        89.20
                facial bone(s).
21029........  Contour of face  .............     2,348.02            2       446.00  .............        89.20
                bone lesion.
21034........  Excise max/      .............     2,348.02            3       510.00  .............       102.00
                zygoma mlg
                tumor.
21040........  Excise mandible  .............     1,434.04            2       446.00  .............        89.20
                lesion.
21044........  Removal of jaw   .............     2,348.02            2       446.00  .............        89.20
                bone lesion.
21046........  Remove mandible  .............     2,348.02            2       446.00  .............        89.20
                cyst complex.
21047........  Excise lwr jaw   .............     2,348.02            2       446.00  .............        89.20
                cyst w/repair.

[[Page 68248]]

 
21050........  Removal of jaw   .............     2,348.02            3       510.00  .............       102.00
                joint.
21060........  Remove jaw       .............     2,348.02            2       446.00  .............        89.20
                joint
                cartilage.
21070........  Remove coronoid  .............     2,348.02            3       510.00  .............       102.00
                process.
21100........  Maxillofacial    .............     2,348.02            2       446.00  .............        89.20
                fixation.
21120........  Reconstruction   .............     1,434.04            7       995.00  .............       199.00
                of chin.
21121........  Reconstruction   .............     1,434.04            7       995.00  .............       199.00
                of chin.
21122........  Reconstruction   .............     1,434.04            7       995.00  .............       199.00
                of chin.
21123........  Reconstruction   .............     1,434.04            7       995.00  .............       199.00
                of chin.
21125........  Augmentation,    .............     1,434.04            7       995.00  .............       199.00
                lower jaw bone.
21127........  Augmentation,    .............     2,348.02            9     1,339.00  .............       267.80
                lower jaw bone.
21181........  Contour cranial  .............     1,434.04            7       995.00  .............       199.00
                bone lesion.
21206........  Reconstruct      .............     2,348.02            5       717.00  .............       143.40
                upper jaw bone.
21208........  Augmentation of  .............     2,348.02            7       995.00  .............       199.00
                facial bones.
21209........  Reduction of     .............     2,348.02            5       717.00  .............       143.40
                facial bones.
21210........  Face bone graft  .............     2,348.02            7       995.00  .............       199.00
21215........  Lower jaw bone   .............     2,348.02            7       995.00  .............       199.00
                graft.
21230........  Rib cartilage    .............     2,348.02            7       995.00  .............       199.00
                graft.
21235........  Ear cartilage    .............     1,434.04            7       995.00  .............       199.00
                graft.
21240........  Reconstruction   .............     2,348.02            4       630.00  .............       126.00
                of jaw joint.
21242........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of jaw joint.
21243........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of jaw joint.
21244........  Reconstruction   .............     2,348.02            7       995.00  .............       199.00
                of lower jaw.
21245........  Reconstruction   .............     2,348.02            7       995.00  .............       199.00
                of jaw.
21246........  Reconstruction   .............     2,348.02            7       995.00  .............       199.00
                of jaw.
21248........  Reconstruction   .............     2,348.02            7       995.00  .............       199.00
                of jaw.
21249........  Reconstruction   .............     2,348.02            7       995.00  .............       199.00
                of jaw.
21267........  Revise eye       .............     2,348.02            7       995.00  .............       199.00
                sockets.
21270........  Augmentation,    .............     2,348.02            5       717.00  .............       143.40
                cheek bone.
21275........  Revision,        .............     2,348.02            7       995.00  .............       199.00
                orbitofacial
                bones.
21280........  Revision of      .............     2,348.02            5       717.00  .............       143.40
                eyelid.
21282........  Revision of      .............     1,009.71            5       717.00  .............       143.40
                eyelid.
21295........  Revision of jaw  .............       464.15            1       333.00  .............        66.60
                muscle/bone.
21296........  Revision of jaw  .............     1,434.04            1       333.00  .............        66.60
                muscle/bone.
21300........  Treatment of     D............  ...........            2       446.00  .............  ...........
                skull fracture.
21310........  Treatment of     .............       150.72            2       150.72  Y............        30.14
                nose fracture.
21315........  Treatment of     .............       150.72            2       150.72  Y............        30.14
                nose fracture.
21320........  Treatment of     .............       464.15            2       446.00  .............        89.20
                nose fracture.
21325........  Treatment of     .............     1,434.04            4       630.00  .............       126.00
                nose fracture.
21330........  Treatment of     .............     1,434.04            5       717.00  .............       143.40
                nose fracture.
21335........  Treatment of     .............     1,434.04            7       995.00  .............       199.00
                nose fracture.
21336........  Treat nasal      .............     2,307.40            4       630.00  .............       126.00
                septal
                fracture.
21337........  Treat nasal      .............     1,009.71            2       446.00  .............        89.20
                septal
                fracture.
21338........  Treat            .............     1,434.04            4       630.00  .............       126.00
                nasoethmoid
                fracture.
21339........  Treat            .............     1,434.04            5       717.00  .............       143.40
                nasoethmoid
                fracture.
21340........  Treatment of     .............     2,348.02            4       630.00  .............       126.00
                nose fracture.
21345........  Treat nose/jaw   .............     1,434.04            7       995.00  .............       199.00
                fracture.
21355........  Treat cheek      .............     2,348.02            3       510.00  .............       102.00
                bone fracture.
21356........  Treat cheek      A*...........     1,434.04            3       510.00  .............       102.00
                bone fracture.
21400........  Treat eye        .............       464.15            2       446.00  .............        89.20
                socket
                fracture.
21401........  Treat eye        .............     1,009.71            3       510.00  .............       102.00
                socket
                fracture.
21421........  Treat mouth      .............     1,434.04            4       630.00  .............       126.00
                roof fracture.
21445........  Treat dental     .............     1,434.04            4       630.00  .............       126.00
                ridge fracture.
21450........  Treat lower jaw  .............       150.72            3       150.72  Y............        30.14
                fracture.
21451........  Treat lower jaw  .............       464.15            4       464.15  Y............        92.83
                fracture.
21452........  Treat lower jaw  .............     1,009.71            2       446.00  .............        89.20
                fracture.
21453........  Treat lower jaw  .............     2,348.02            3       510.00  .............       102.00
                fracture.
21454........  Treat lower jaw  .............     1,434.04            5       717.00  .............       143.40
                fracture.
21461........  Treat lower jaw  .............     2,348.02            4       630.00  .............       126.00
                fracture.
21462........  Treat lower jaw  .............     2,348.02            5       717.00  .............       143.40
                fracture.
21465........  Treat lower jaw  .............     2,348.02            4       630.00  .............       126.00
                fracture.
21480........  Reset            .............       150.72            1       150.72  Y............        30.14
                dislocated jaw.
21485........  Reset            .............     1,009.71            2       446.00  .............        89.20
                dislocated jaw.
21490........  Repair           .............     2,348.02            3       510.00  .............       102.00
                dislocated jaw.
21497........  Interdental      .............     1,009.71            2       446.00  .............        89.20
                wiring.
21501........  Drain neck/      .............     1,076.22            2       446.00  .............        89.20
                chest lesion.

[[Page 68249]]

 
21502........  Drain chest      .............     1,282.87            2       446.00  .............        89.20
                lesion.
21555........  Remove lesion,   .............     1,233.39            2       446.00  .............        89.20
                neck/chest.
21556........  Remove lesion,   .............     1,233.39            2       446.00  .............        89.20
                neck/chest.
21600........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of rib.
21610........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of rib.
21700........  Revision of      .............     1,282.87            2       446.00  .............        89.20
                neck muscle.
21720........  Revision of      .............     1,282.87            3       510.00  .............       102.00
                neck muscle.
21725........  Revision of      .............        88.46            3        88.46  Y............        17.69
                neck muscle.
21800........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                rib fracture.
21805........  Treatment of     .............     1,569.06            2       446.00  .............        89.20
                rib fracture.
21820........  Treat sternum    .............       103.62            1       103.62  Y............        20.72
                fracture.
21925........  Biopsy soft      .............     1,233.39            2       446.00  .............        89.20
                tissue of back.
21930........  Remove lesion,   .............     1,233.39            2       446.00  .............        89.20
                back or flank.
21935........  Remove tumor,    .............     1,233.39            3       510.00  .............       102.00
                back.
22305........  Treat spine      .............       103.62            1       103.62  Y............        20.72
                process
                fracture.
22310........  Treat spine      .............       103.62            1       103.62  Y............        20.72
                fracture.
22315........  Treat spine      .............       103.62            2       103.62  Y............        20.72
                fracture.
22505........  Manipulation of  .............       897.11            2       446.00  .............        89.20
                spine.
22520........  Percut           A*...........     1,544.67            9     1,339.00  .............       267.80
                vertebroplasty
                thor.
22521........  Percut           A*...........     1,544.67            9     1,339.00  .............       267.80
                vertebroplasty
                lumb.
22522........  Percut           A*...........     1,544.67            9     1,339.00  .............       267.80
                vertebroplasty
                add[AElig].
22900........  Remove           .............     1,233.39            4       630.00  .............       126.00
                abdominal wall
                lesion.
23000........  Removal of       .............       928.31            2       446.00  .............        89.20
                calcium
                deposits.
23020........  Release          .............     2,525.68            2       446.00  .............        89.20
                shoulder joint.
23030........  Drain shoulder   .............     1,076.22            1       333.00  .............        66.60
                lesion.
23031........  Drain shoulder   .............     1,076.22            3       510.00  .............       102.00
                bursa.
23035........  Drain shoulder   .............     1,282.87            3       510.00  .............       102.00
                bone lesion.
23040........  Exploratory      .............     1,544.67            3       510.00  .............       102.00
                shoulder
                surgery.
23044........  Exploratory      .............     1,544.67            4       630.00  .............       126.00
                shoulder
                surgery.
23066........  Biopsy shoulder  .............     1,233.39            2       446.00  .............        89.20
                tissues.
23075........  Removal of       .............       928.31            2       446.00  .............        89.20
                shoulder
                lesion.
23076........  Removal of       .............     1,233.39            2       446.00  .............        89.20
                shoulder
                lesion.
23077........  Remove tumor of  .............     1,233.39            3       510.00  .............       102.00
                shoulder.
23100........  Biopsy of        .............     1,282.87            2       446.00  .............        89.20
                shoulder joint.
23101........  Shoulder joint   .............     1,544.67            7       995.00  .............       199.00
                surgery.
23105........  Remove shoulder  .............     1,544.67            4       630.00  .............       126.00
                joint lining.
23106........  Incision of      .............     1,544.67            4       630.00  .............       126.00
                collarbone
                joint.
23107........  Explore treat    .............     1,544.67            4       630.00  .............       126.00
                shoulder joint.
23120........  Partial          .............     2,525.68            5       717.00  .............       143.40
                removal,
                collar bone.
23125........  Removal of       .............     2,525.68            5       717.00  .............       143.40
                collar bone.
23130........  Remove shoulder  .............     2,525.68            5       717.00  .............       143.40
                bone, part.
23140........  Removal of bone  .............     1,282.87            4       630.00  .............       126.00
                lesion.
23145........  Removal of bone  .............     1,544.67            5       717.00  .............       143.40
                lesion.
23146........  Removal of bone  .............     1,544.67            5       717.00  .............       143.40
                lesion.
23150........  Removal of       .............     1,544.67            4       630.00  .............       126.00
                humerus lesion.
23155........  Removal of       .............     1,544.67            5       717.00  .............       143.40
                humerus lesion.
23156........  Removal of       .............     1,544.67            5       717.00  .............       143.40
                humerus lesion.
23170........  Remove collar    .............     1,544.67            2       446.00  .............        89.20
                bone lesion.
23172........  Remove shoulder  .............     1,544.67            2       446.00  .............        89.20
                blade lesion.
23174........  Remove humerus   .............     1,544.67            2       446.00  .............        89.20
                lesion.
23180........  Remove collar    .............     1,544.67            4       630.00  .............       126.00
                bone lesion.
23182........  Remove shoulder  .............     1,544.67            4       630.00  .............       126.00
                blade lesion.
23184........  Remove humerus   .............     1,544.67            4       630.00  .............       126.00
                lesion.
23190........  Partial removal  .............     1,544.67            4       630.00  .............       126.00
                of scapula.
23195........  Removal of head  .............     1,544.67            5       717.00  .............       143.40
                of humerus.
23330........  Remove shoulder  .............       418.49            1       333.00  .............        66.60
                foreign body.
23331........  Remove shoulder  .............     1,233.39            1       333.00  .............        66.60
                foreign body.
23395........  Muscle           .............     2,525.68            5       717.00  .............       143.40
                transfer,shoul
                der/arm.
23397........  Muscle           .............     4,092.54            7       995.00  .............       199.00
                transfers.
23400........  Fixation of      .............     1,544.67            7       995.00  .............       199.00
                shoulder blade.
23405........  Incision of      .............     1,544.67            2       446.00  .............        89.20
                tendon &
                muscle.
23406........  Incise           .............     1,544.67            2       446.00  .............        89.20
                tendon(s) &
                muscle(s).
23410........  Repair rotator   .............     2,525.68            5       717.00  .............       143.40
                cuff, acute.
23412........  Repair rotator   .............     2,525.68            7       995.00  .............       199.00
                cuff, chronic.
23415........  Release of       .............     2,525.68            5       717.00  .............       143.40
                shoulder
                ligament.

[[Page 68250]]

 
23420........  Repair of        .............     2,525.68            7       995.00  .............       199.00
                shoulder.
23430........  Repair biceps    .............     2,525.68            4       630.00  .............       126.00
                tendon.
23440........  Remove/          .............     2,525.68            4       630.00  .............       126.00
                transplant
                tendon.
23450........  Repair shoulder  .............     4,092.54            5       717.00  .............       143.40
                capsule.
23455........  Repair shoulder  .............     4,092.54            7       995.00  .............       199.00
                capsule.
23460........  Repair shoulder  .............     4,092.54            5       717.00  .............       143.40
                capsule.
23462........  Repair shoulder  .............     2,525.68            7       995.00  .............       199.00
                capsule.
23465........  Repair shoulder  .............     4,092.54            5       717.00  .............       143.40
                capsule.
23466........  Repair shoulder  .............     2,525.68            7       995.00  .............       199.00
                capsule.
23480........  Revision of      .............     2,525.68            4       630.00  .............       126.00
                collar bone.
23485........  Revision of      .............     4,092.54            7       995.00  .............       199.00
                collar bone.
23490........  Reinforce        .............     2,525.68            3       510.00  .............       102.00
                clavicle.
23491........  Reinforce        .............     4,092.54            3       510.00  .............       102.00
                shoulder bones.
23500........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                fracture.
23505........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                fracture.
23515........  Treat clavicle   .............     3,517.03            3       510.00  .............       102.00
                fracture.
23520........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                dislocation.
23525........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                dislocation.
23530........  Treat clavicle   .............     2,307.40            3       510.00  .............       102.00
                dislocation.
23532........  Treat clavicle   .............     1,569.06            4       630.00  .............       126.00
                dislocation.
23540........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                dislocation.
23545........  Treat clavicle   .............       103.62            1       103.62  Y............        20.72
                dislocation.
23550........  Treat clavicle   .............     2,307.40            3       510.00  .............       102.00
                dislocation.
23552........  Treat clavicle   .............     2,307.40            4       630.00  .............       126.00
                dislocation.
23570........  Treat shoulder   .............       103.62            1       103.62  Y............        20.72
                blade fx.
23575........  Treat shoulder   .............       103.62            1       103.62  Y............        20.72
                blade fx.
23585........  Treat scapula    .............     3,517.03            3       510.00  .............       102.00
                fracture.
23605........  Treat humerus    .............       103.62            2       103.62  Y............        20.72
                fracture.
23615........  Treat humerus    .............     3,517.03            4       630.00  .............       126.00
                fracture.
23616........  Treat humerus    .............     3,517.03            4       630.00  .............       126.00
                fracture.
23625........  Treat humerus    .............       103.62            2       103.62  Y............        20.72
                fracture.
23630........  Treat humerus    .............     3,517.03            5       717.00  .............       143.40
                fracture.
23650........  Treat shoulder   .............       103.62            1       103.62  Y............        20.72
                dislocation.
23655........  Treat shoulder   .............       897.11            1       333.00  .............        66.60
                dislocation.
23660........  Treat shoulder   .............     2,307.40            3       510.00  .............       102.00
                dislocation.
23665........  Treat            .............       103.62            2       103.62  Y............        20.72
                dislocation/
                fracture.
23670........  Treat            .............     3,517.03            3       510.00  .............       102.00
                dislocation/
                fracture.
23675........  Treat            .............       103.62            2       103.62  Y............        20.72
                dislocation/
                fracture.
23680........  Treat            .............     2,307.40            3       510.00  .............       102.00
                dislocation/
                fracture.
23700........  Fixation of      .............       897.11            1       333.00  .............        66.60
                shoulder.
23800........  Fusion of        .............     4,092.54            4       630.00  .............       126.00
                shoulder joint.
23802........  Fusion of        .............     2,525.68            7       995.00  .............       199.00
                shoulder joint.
23921........  Amputation       .............       323.28            3       323.28  Y............        64.66
                follow-up
                surgery.
23930........  Drainage of arm  .............     1,076.22            1       333.00  .............        66.60
                lesion.
23931........  Drainage of arm  .............     1,076.22            2       446.00  .............        89.20
                bursa.
23935........  Drain arm/elbow  .............     1,282.87            2       446.00  .............        89.20
                bone lesion.
24000........  Exploratory      .............     1,544.67            4       630.00  .............       126.00
                elbow surgery.
24006........  Release elbow    .............     1,544.67            4       630.00  .............       126.00
                joint.
24066........  Biopsy arm/      .............       928.31            2       446.00  .............        89.20
                elbow soft
                tissue.
24075........  Remove arm/      .............       928.31            2       446.00  .............        89.20
                elbow lesion.
24076........  Remove arm/      .............     1,233.39            2       446.00  .............        89.20
                elbow lesion.
24077........  Remove tumor of  .............     1,233.39            3       510.00  .............       102.00
                arm/elbow.
24100........  Biopsy elbow     .............     1,282.87            1       333.00  .............        66.60
                joint lining.
24101........  Explore/treat    .............     1,544.67            4       630.00  .............       126.00
                elbow joint.
24102........  Remove elbow     .............     1,544.67            4       630.00  .............       126.00
                joint lining.
24105........  Removal of       .............     1,282.87            3       510.00  .............       102.00
                elbow bursa.
24110........  Remove humerus   .............     1,282.87            2       446.00  .............        89.20
                lesion.
24115........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                bone lesion.
24116........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                bone lesion.
24120........  Remove elbow     .............     1,282.87            3       510.00  .............       102.00
                lesion.
24125........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                bone lesion.
24126........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                bone lesion.
24130........  Removal of head  .............     1,544.67            3       510.00  .............       102.00
                of radius.
24134........  Removal of arm   .............     1,544.67            2       446.00  .............        89.20
                bone lesion.
24136........  Remove radius    .............     1,544.67            2       446.00  .............        89.20
                bone lesion.

[[Page 68251]]

 
24138........  Remove elbow     .............     1,544.67            2       446.00  .............        89.20
                bone lesion.
24140........  Partial removal  .............     1,544.67            3       510.00  .............       102.00
                of arm bone.
24145........  Partial removal  .............     1,544.67            3       510.00  .............       102.00
                of radius.
24147........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of elbow.
24155........  Removal of       .............     2,525.68            3       510.00  .............       102.00
                elbow joint.
24160........  Remove elbow     .............     1,544.67            2       446.00  .............        89.20
                joint implant.
24164........  Remove radius    .............     1,544.67            3       510.00  .............       102.00
                head implant.
24201........  Removal of arm   .............       928.31            2       446.00  .............        89.20
                foreign body.
24301........  Muscle/tendon    .............     1,544.67            4       630.00  .............       126.00
                transfer.
24305........  Arm tendon       .............     1,544.67            4       630.00  .............       126.00
                lengthening.
24310........  Revision of arm  .............     1,282.87            3       510.00  .............       102.00
                tendon.
24320........  Repair of arm    .............     2,525.68            3       510.00  .............       102.00
                tendon.
24330........  Revision of arm  .............     4,092.54            3       510.00  .............       102.00
                muscles.
24331........  Revision of arm  .............     2,525.68            3       510.00  .............       102.00
                muscles.
24340........  Repair of        .............     2,525.68            3       510.00  .............       102.00
                biceps tendon.
24341........  Repair arm       .............     2,525.68            3       510.00  .............       102.00
                tendon/muscle.
24342........  Repair of        .............     2,525.68            3       510.00  .............       102.00
                ruptured
                tendon.
24345........  Repr elbw med    .............     1,544.67            2       446.00  .............        89.20
                ligmnt w/tissu.
24350........  Repair of        .............     1,544.67            3       510.00  .............       102.00
                tennis elbow.
24351........  Repair of        .............     1,544.67            3       510.00  .............       102.00
                tennis elbow.
24352........  Repair of        .............     1,544.67            3       510.00  .............       102.00
                tennis elbow.
24354........  Repair of        .............     1,544.67            3       510.00  .............       102.00
                tennis elbow.
24356........  Revision of      .............     1,544.67            3       510.00  .............       102.00
                tennis elbow.
24360........  Reconstruct      .............     2,056.14            5       717.00  .............       143.40
                elbow joint.
24361........  Reconstruct      .............     6,589.01            5       717.00  .............       143.40
                elbow joint.
24362........  Reconstruct      .............     2,915.91            5       717.00  .............       143.40
                elbow joint.
24363........  Replace elbow    .............     6,589.01            7       995.00  .............       199.00
                joint.
24365........  Reconstruct      .............     2,056.14            5       717.00  .............       143.40
                head of radius.
24366........  Reconstruct      .............     6,589.01            5       717.00  .............       143.40
                head of radius.
24400........  Revision of      .............     1,544.67            4       630.00  .............       126.00
                humerus.
24410........  Revision of      .............     1,544.67            4       630.00  .............       126.00
                humerus.
24420........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                humerus.
24430........  Repair of        .............     4,092.54            3       510.00  .............       102.00
                humerus.
24435........  Repair humerus   .............     4,092.54            4       630.00  .............       126.00
                with graft.
24470........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                elbow joint.
24495........  Decompression    .............     1,544.67            2       446.00  .............        89.20
                of forearm.
24498........  Reinforce        .............     4,092.54            3       510.00  .............       102.00
                humerus.
24500........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24505........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24515........  Treat humerus    .............     3,517.03            4       630.00  .............       126.00
                fracture.
24516........  Treat humerus    .............     3,517.03            4       630.00  .............       126.00
                fracture.
24530........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24535........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24538........  Treat humerus    .............     1,569.06            2       446.00  .............        89.20
                fracture.
24545........  Treat humerus    .............     3,517.03            4       630.00  .............       126.00
                fracture.
24546........  Treat humerus    .............     3,517.03            5       717.00  .............       143.40
                fracture.
24560........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24565........  Treat humerus    .............       103.62            2       103.62  Y............        20.72
                fracture.
24566........  Treat humerus    .............     1,569.06            2       446.00  .............        89.20
                fracture.
24575........  Treat humerus    .............     3,517.03            3       510.00  .............       102.00
                fracture.
24576........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24577........  Treat humerus    .............       103.62            1       103.62  Y............        20.72
                fracture.
24579........  Treat humerus    .............     3,517.03            3       510.00  .............       102.00
                fracture.
24582........  Treat humerus    .............     1,569.06            2       446.00  .............        89.20
                fracture.
24586........  Treat elbow      .............     3,517.03            4       630.00  .............       126.00
                fracture.
24587........  Treat elbow      .............     3,517.03            5       717.00  .............       143.40
                fracture.
24600........  Treat elbow      .............       103.62            1       103.62  Y............        20.72
                dislocation.
24605........  Treat elbow      .............       897.11            2       446.00  .............        89.20
                dislocation.
24615........  Treat elbow      .............     3,517.03            3       510.00  .............       102.00
                dislocation.
24620........  Treat elbow      .............       103.62            2       103.62  Y............        20.72
                fracture.
24635........  Treat elbow      .............     3,517.03            3       510.00  .............       102.00
                fracture.
24655........  Treat radius     .............       103.62            1       103.62  Y............        20.72
                fracture.
24665........  Treat radius     .............     2,307.40            4       630.00  .............       126.00
                fracture.
24666........  Treat radius     .............     3,517.03            4       630.00  .............       126.00
                fracture.
24670........  Treat ulnar      .............       103.62            1       103.62  Y............        20.72
                fracture.

[[Page 68252]]

 
24675........  Treat ulnar      .............       103.62            1       103.62  Y............        20.72
                fracture.
24685........  Treat ulnar      .............     2,307.40            3       510.00  .............       102.00
                fracture.
24800........  Fusion of elbow  .............     2,525.68            4       630.00  .............       126.00
                joint.
24802........  Fusion/graft of  .............     2,525.68            5       717.00  .............       143.40
                elbow joint.
24925........  Amputation       .............     1,282.87            3       510.00  .............       102.00
                follow-up
                surgery.
25000........  Incision of      .............     1,282.87            3       510.00  .............       102.00
                tendon sheath.
25020........  Decompress       .............     1,282.87            3       510.00  .............       102.00
                forearm 1
                space.
25023........  Decompress       .............     1,544.67            3       510.00  .............       102.00
                forearm 1
                space.
25024........  Decompress       .............     1,544.67            3       510.00  .............       102.00
                forearm 2
                spaces.
25025........  Decompress       .............     1,544.67            3       510.00  .............       102.00
                forearm 2
                spaces.
25028........  Drainage of      .............     1,282.87            1       333.00  .............        66.60
                forearm lesion.
25031........  Drainage of      .............     1,282.87            2       446.00  .............        89.20
                forearm bursa.
25035........  Treat forearm    .............     1,282.87            2       446.00  .............        89.20
                bone lesion.
25040........  Explore/treat    .............     1,544.67            5       717.00  .............       143.40
                wrist joint.
25066........  Biopsy forearm   .............     1,233.39            2       446.00  .............        89.20
                soft tissues.
25075........  Removal forearm  .............       928.31            2       446.00  .............        89.20
                lesion subcu.
25076........  Removal forearm  .............     1,233.39            3       510.00  .............       102.00
                lesion deep.
25077........  Remove tumor,    .............     1,233.39            3       510.00  .............       102.00
                forearm/wrist.
25085........  Incision of      .............     1,282.87            3       510.00  .............       102.00
                wrist capsule.
25100........  Biopsy of wrist  .............     1,282.87            2       446.00  .............        89.20
                joint.
25101........  Explore/treat    .............     1,544.67            3       510.00  .............       102.00
                wrist joint.
25105........  Remove wrist     .............     1,544.67            4       630.00  .............       126.00
                joint lining.
25107........  Remove wrist     .............     1,544.67            3       510.00  .............       102.00
                joint
                cartilage.
25110........  Remove wrist     .............     1,282.87            3       510.00  .............       102.00
                tendon lesion.
25111........  Remove wrist     .............       992.95            3       510.00  .............       102.00
                tendon lesion.
25112........  Remove wrist     .............       992.95            4       630.00  .............       126.00
                tendon lesion.
25115........  Remove wrist/    .............     1,282.87            4       630.00  .............       126.00
                forearm lesion.
25116........  Remove wrist/    .............     1,282.87            4       630.00  .............       126.00
                forearm lesion.
25118........  Excise wrist     .............     1,544.67            2       446.00  .............        89.20
                tendon sheath.
25119........  Partial removal  .............     1,544.67            3       510.00  .............       102.00
                of ulna.
25120........  Removal of       .............     1,544.67            3       510.00  .............       102.00
                forearm lesion.
25125........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                forearm lesion.
25126........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                forearm lesion.
25130........  Removal of       .............     1,544.67            3       510.00  .............       102.00
                wrist lesion.
25135........  Remove & graft   .............     1,544.67            3       510.00  .............       102.00
                wrist lesion.
25136........  Remove & graft   .............     1,544.67            3       510.00  .............       102.00
                wrist lesion.
25145........  Remove forearm   .............     1,544.67            2       446.00  .............        89.20
                bone lesion.
25150........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of ulna.
25151........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of radius.
25210........  Removal of       .............     1,590.53            3       510.00  .............       102.00
                wrist bone.
25215........  Removal of       .............     1,590.53            4       630.00  .............       126.00
                wrist bones.
25230........  Partial removal  .............     1,544.67            4       630.00  .............       126.00
                of radius.
25240........  Partial removal  .............     1,544.67            4       630.00  .............       126.00
                of ulna.
25248........  Remove forearm   .............     1,282.87            2       446.00  .............        89.20
                foreign body.
25250........  Removal of       .............     1,544.67            1       333.00  .............        66.60
                wrist
                prosthesis.
25251........  Removal of       .............     1,544.67            1       333.00  .............        66.60
                wrist
                prosthesis.
25260........  Repair forearm   .............     1,544.67            4       630.00  .............       126.00
                tendon/muscle.
25263........  Repair forearm   .............     1,544.67            2       446.00  .............        89.20
                tendon/muscle.
25265........  Repair forearm   .............     1,544.67            3       510.00  .............       102.00
                tendon/muscle.
25270........  Repair forearm   .............     1,544.67            4       630.00  .............       126.00
                tendon/muscle.
25272........  Repair forearm   .............     1,544.67            3       510.00  .............       102.00
                tendon/muscle.
25274........  Repair forearm   .............     1,544.67            4       630.00  .............       126.00
                tendon/muscle.
25275........  Repair forearm   .............     1,544.67            4       630.00  .............       126.00
                tendon sheath.
25280........  Revise wrist/    .............     1,544.67            4       630.00  .............       126.00
                forearm tendon.
25290........  Incise wrist/    .............     1,544.67            3       510.00  .............       102.00
                forearm tendon.
25295........  Release wrist/   .............     1,282.87            3       510.00  .............       102.00
                forearm tendon.
25300........  Fusion of        .............     1,544.67            3       510.00  .............       102.00
                tendons at
                wrist.
25301........  Fusion of        .............     1,544.67            3       510.00  .............       102.00
                tendons at
                wrist.
25310........  Transplant       .............     2,525.68            3       510.00  .............       102.00
                forearm tendon.
25312........  Transplant       .............     2,525.68            4       630.00  .............       126.00
                forearm tendon.
25315........  Revise palsy     .............     2,525.68            3       510.00  .............       102.00
                hand tendon(s).
25316........  Revise palsy     .............     4,092.54            3       510.00  .............       102.00
                hand tendon(s).
25320........  Repair/revise    .............     2,525.68            3       510.00  .............       102.00
                wrist joint.
25332........  Revise wrist     .............     2,056.14            5       717.00  .............       143.40
                joint.
25335........  Realignment of   .............     2,525.68            3       510.00  .............       102.00
                hand.

[[Page 68253]]

 
25337........  Reconstruct      .............     2,525.68            5       717.00  .............       143.40
                ulna/
                radioulnar.
25350........  Revision of      .............     4,092.54            3       510.00  .............       102.00
                radius.
25355........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                radius.
25360........  Revision of      .............     1,544.67            3       510.00  .............       102.00
                ulna.
25365........  Revise radius &  .............     1,544.67            3       510.00  .............       102.00
                ulna.
25370........  Revise radius    .............     2,525.68            3       510.00  .............       102.00
                or ulna.
25375........  Revise radius &  .............     2,525.68            4       630.00  .............       126.00
                ulna.
25390........  Shorten radius   .............     1,544.67            3       510.00  .............       102.00
                or ulna.
25391........  Lengthen radius  .............     2,525.68            4       630.00  .............       126.00
                or ulna.
25392........  Shorten radius   .............     1,544.67            3       510.00  .............       102.00
                & ulna.
25393........  Lengthen radius  .............     2,525.68            4       630.00  .............       126.00
                & ulna.
25400........  Repair radius    .............     1,544.67            3       510.00  .............       102.00
                or ulna.
25405........  Repair/graft     .............     1,544.67            4       630.00  .............       126.00
                radius or ulna.
25415........  Repair radius &  .............     1,544.67            3       510.00  .............       102.00
                ulna.
25420........  Repair/graft     .............     4,092.54            4       630.00  .............       126.00
                radius & ulna.
25425........  Repair/graft     .............     2,525.68            3       510.00  .............       102.00
                radius or ulna.
25426........  Repair/graft     .............     2,525.68            4       630.00  .............       126.00
                radius & ulna.
25440........  Repair/graft     .............     4,092.54            4       630.00  .............       126.00
                wrist bone.
25441........  Reconstruct      .............     6,589.01            5       717.00  .............       143.40
                wrist joint.
25442........  Reconstruct      .............     6,589.01            5       717.00  .............       143.40
                wrist joint.
25443........  Reconstruct      .............     2,915.91            5       717.00  .............       143.40
                wrist joint.
25444........  Reconstruct      .............     2,915.91            5       717.00  .............       143.40
                wrist joint.
25445........  Reconstruct      .............     2,915.91            5       717.00  .............       143.40
                wrist joint.
25446........  Wrist            .............     6,589.01            7       995.00  .............       199.00
                replacement.
25447........  Repair wrist     .............     2,056.14            5       717.00  .............       143.40
                joint(s).
25449........  Remove wrist     .............     2,056.14            5       717.00  .............       143.40
                joint implant.
25450........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                wrist joint.
25455........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                wrist joint.
25490........  Reinforce        .............     2,525.68            3       510.00  .............       102.00
                radius.
25491........  Reinforce ulna.  .............     2,525.68            3       510.00  .............       102.00
25492........  Reinforce        .............     2,525.68            3       510.00  .............       102.00
                radius and
                ulna.
25505........  Treat fracture   .............       103.62            1       103.62  Y............        20.72
                of radius.
25515........  Treat fracture   .............     2,307.40            3       510.00  .............       102.00
                of radius.
25520........  Treat fracture   .............       103.62            1       103.62  Y............        20.72
                of radius.
25525........  Treat fracture   .............     2,307.40            4       630.00  .............       126.00
                of radius.
25526........  Treat fracture   .............     2,307.40            5       717.00  .............       143.40
                of radius.
25535........  Treat fracture   .............       103.62            1       103.62  Y............        20.72
                of ulna.
25545........  Treat fracture   .............     2,307.40            3       510.00  .............       102.00
                of ulna.
25565........  Treat fracture   .............       103.62            2       103.62  Y............        20.72
                radius & ulna.
25574........  Treat fracture   .............     3,517.03            3       510.00  .............       102.00
                radius & ulna.
25575........  Treat fracture   .............     3,517.03            3       510.00  .............       102.00
                radius/ulna.
25605........  Treat fracture   .............       103.62            3       103.62  Y............        20.72
                radius/ulna.
25606........  Treat fx distal  A............     1,569.06            3       510.00  .............       102.00
                radial.
25607........  Treat fx rad     A............     3,517.03            5       717.00  .............       143.40
                extra-articul.
25608........  Treat fx rad     A............     3,517.03            5       717.00  .............       143.40
                intra-articul.
25609........  Treat fx radial  A............     3,517.03            5       717.00  .............       143.40
                3+ frag.
25611........  Treat fracture   D............  ...........            3       510.00  .............  ...........
                radius/ulna.
25620........  Treat fracture   D............  ...........            5       717.00  .............  ...........
                radius/ulna.
25624........  Treat wrist      .............       103.62            2       103.62  Y............        20.72
                bone fracture.
25628........  Treat wrist      .............     2,307.40            3       510.00  .............       102.00
                bone fracture.
25635........  Treat wrist      .............       103.62            1       103.62  Y............        20.72
                bone fracture.
25645........  Treat wrist      .............     2,307.40            3       510.00  .............       102.00
                bone fracture.
25660........  Treat wrist      .............       103.62            1       103.62  Y............        20.72
                dislocation.
25670........  Treat wrist      .............     1,569.06            3       510.00  .............       102.00
                dislocation.
25671........  Pin radioulnar   .............     1,569.06            1       333.00  .............        66.60
                dislocation.
25675........  Treat wrist      .............       103.62            1       103.62  Y............        20.72
                dislocation.
25676........  Treat wrist      .............     1,569.06            2       446.00  .............        89.20
                dislocation.
25680........  Treat wrist      .............       103.62            2       103.62  Y............        20.72
                fracture.
25685........  Treat wrist      .............     1,569.06            3       510.00  .............       102.00
                fracture.
25690........  Treat wrist      .............       103.62            1       103.62  Y............        20.72
                dislocation.
25695........  Treat wrist      .............     1,569.06            2       446.00  .............        89.20
                dislocation.
25800........  Fusion of wrist  .............     4,092.54            4       630.00  .............       126.00
                joint.
25805........  Fusion/graft of  .............     2,525.68            5       717.00  .............       143.40
                wrist joint.
25810........  Fusion/graft of  .............     4,092.54            5       717.00  .............       143.40
                wrist joint.
25820........  Fusion of hand   .............       992.95            4       630.00  .............       126.00
                bones.

[[Page 68254]]

 
25825........  Fuse hand bones  .............     1,590.53            5       717.00  .............       143.40
                with graft.
25830........  Fusion,          .............     4,092.54            5       717.00  .............       143.40
                radioulnar jnt/
                ulna.
25907........  Amputation       .............     1,282.87            3       510.00  .............       102.00
                follow-up
                surgery.
25922........  Amputate hand    .............     1,282.87            3       510.00  .............       102.00
                at wrist.
25929........  Amputation       .............       862.68            3       510.00  .............       102.00
                follow-up
                surgery.
26011........  Drainage of      .............       685.58            1       333.00  .............        66.60
                finger abscess.
26020........  Drain hand       .............       992.95            2       446.00  .............        89.20
                tendon sheath.
26025........  Drainage of      .............       992.95            1       333.00  .............        66.60
                palm bursa.
26030........  Drainage of      .............       992.95            2       446.00  .............        89.20
                palm bursa(s).
26034........  Treat hand bone  .............       992.95            2       446.00  .............        89.20
                lesion.
26040........  Release palm     .............     1,590.53            4       630.00  .............       126.00
                contracture.
26045........  Release palm     .............     1,590.53            3       510.00  .............       102.00
                contracture.
26055........  Incise finger    .............       992.95            2       446.00  .............        89.20
                tendon sheath.
26060........  Incision of      .............       992.95            2       446.00  .............        89.20
                finger tendon.
26070........  Explore/treat    .............       992.95            2       446.00  .............        89.20
                hand joint.
26075........  Explore/treat    .............       992.95            4       630.00  .............       126.00
                finger joint.
26080........  Explore/treat    .............       992.95            4       630.00  .............       126.00
                finger joint.
26100........  Biopsy hand      .............       992.95            2       446.00  .............        89.20
                joint lining.
26105........  Biopsy finger    .............       992.95            1       333.00  .............        66.60
                joint lining.
26110........  Biopsy finger    .............       992.95            1       333.00  .............        66.60
                joint lining.
26115........  Removal hand     .............     1,233.39            2       446.00  .............        89.20
                lesion subcut.
26116........  Removal hand     .............     1,233.39            2       446.00  .............        89.20
                lesion, deep.
26117........  Remove tumor,    .............     1,233.39            3       510.00  .............       102.00
                hand/finger.
26121........  Release palm     .............     1,590.53            4       630.00  .............       126.00
                contracture.
26123........  Release palm     .............     1,590.53            4       630.00  .............       126.00
                contracture.
26125........  Release palm     .............       992.95            4       630.00  .............       126.00
                contracture.
26130........  Remove wrist     .............       992.95            3       510.00  .............       102.00
                joint lining.
26135........  Revise finger    .............     1,590.53            4       630.00  .............       126.00
                joint, each.
26140........  Revise finger    .............       992.95            2       446.00  .............        89.20
                joint, each.
26145........  Tendon           .............       992.95            3       510.00  .............       102.00
                excision, palm/
                finger.
26160........  Remove tendon    .............       992.95            3       510.00  .............       102.00
                sheath lesion.
26170........  Removal of palm  .............       992.95            3       510.00  .............       102.00
                tendon, each.
26180........  Removal of       .............       992.95            3       510.00  .............       102.00
                finger tendon.
26185........  Remove finger    .............       992.95            4       630.00  .............       126.00
                bone.
26200........  Remove hand      .............       992.95            2       446.00  .............        89.20
                bone lesion.
26205........  Remove/graft     .............     1,590.53            3       510.00  .............       102.00
                bone lesion.
26210........  Removal of       .............       992.95            2       446.00  .............        89.20
                finger lesion.
26215........  Remove/graft     .............       992.95            3       510.00  .............       102.00
                finger lesion.
26230........  Partial removal  .............       992.95            7       992.95  Y............       198.59
                of hand bone.
26235........  Partial          .............       992.95            3       510.00  .............       102.00
                removal,
                finger bone.
26236........  Partial          .............       992.95            3       510.00  .............       102.00
                removal,
                finger bone.
26250........  Extensive hand   .............       992.95            3       510.00  .............       102.00
                surgery.
26255........  Extensive hand   .............     1,590.53            3       510.00  .............       102.00
                surgery.
26260........  Extensive        .............       992.95            3       510.00  .............       102.00
                finger surgery.
26261........  Extensive        .............       992.95            3       510.00  .............       102.00
                finger surgery.
26262........  Partial removal  .............       992.95            2       446.00  .............        89.20
                of finger.
26320........  Removal of       .............       928.31            2       446.00  .............        89.20
                implant from
                hand.
26350........  Repair finger/   .............     1,590.53            1       333.00  .............        66.60
                hand tendon.
26352........  Repair/graft     .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26356........  Repair finger/   .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26357........  Repair finger/   .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26358........  Repair/graft     .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26370........  Repair finger/   .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26372........  Repair/graft     .............     1,590.53            4       630.00  .............       126.00
                hand tendon.
26373........  Repair finger/   .............     1,590.53            3       510.00  .............       102.00
                hand tendon.
26390........  Revise hand/     .............     1,590.53            4       630.00  .............       126.00
                finger tendon.
26392........  Repair/graft     .............     1,590.53            3       510.00  .............       102.00
                hand tendon.
26410........  Repair hand      .............       992.95            3       510.00  .............       102.00
                tendon.
26412........  Repair/graft     .............     1,590.53            3       510.00  .............       102.00
                hand tendon.
26415........  Excision, hand/  .............     1,590.53            4       630.00  .............       126.00
                finger tendon.
26416........  Graft hand or    .............     1,590.53            3       510.00  .............       102.00
                finger tendon.
26418........  Repair finger    .............       992.95            4       630.00  .............       126.00
                tendon.
26420........  Repair/graft     .............     1,590.53            4       630.00  .............       126.00
                finger tendon.
26426........  Repair finger/   .............     1,590.53            3       510.00  .............       102.00
                hand tendon.
26428........  Repair/graft     .............     1,590.53            3       510.00  .............       102.00
                finger tendon.

[[Page 68255]]

 
26432........  Repair finger    .............       992.95            3       510.00  .............       102.00
                tendon.
26433........  Repair finger    .............       992.95            3       510.00  .............       102.00
                tendon.
26434........  Repair/graft     .............     1,590.53            3       510.00  .............       102.00
                finger tendon.
26437........  Realignment of   .............       992.95            3       510.00  .............       102.00
                tendons.
26440........  Release palm/    .............       992.95            3       510.00  .............       102.00
                finger tendon.
26442........  Release palm &   .............     1,590.53            3       510.00  .............       102.00
                finger tendon.
26445........  Release hand/    .............       992.95            3       510.00  .............       102.00
                finger tendon.
26449........  Release forearm/ .............     1,590.53            3       510.00  .............       102.00
                hand tendon.
26450........  Incision of      .............       992.95            3       510.00  .............       102.00
                palm tendon.
26455........  Incision of      .............       992.95            3       510.00  .............       102.00
                finger tendon.
26460........  Incise hand/     .............       992.95            3       510.00  .............       102.00
                finger tendon.
26471........  Fusion of        .............       992.95            2       446.00  .............        89.20
                finger tendons.
26474........  Fusion of        .............       992.95            2       446.00  .............        89.20
                finger tendons.
26476........  Tendon           .............       992.95            1       333.00  .............        66.60
                lengthening.
26477........  Tendon           .............       992.95            1       333.00  .............        66.60
                shortening.
26478........  Lengthening of   .............       992.95            1       333.00  .............        66.60
                hand tendon.
26479........  Shortening of    .............       992.95            1       333.00  .............        66.60
                hand tendon.
26480........  Transplant hand  .............     1,590.53            3       510.00  .............       102.00
                tendon.
26483........  Transplant/      .............     1,590.53            3       510.00  .............       102.00
                graft hand
                tendon.
26485........  Transplant palm  .............     1,590.53            2       446.00  .............        89.20
                tendon.
26489........  Transplant/      .............     1,590.53            3       510.00  .............       102.00
                graft palm
                tendon.
26490........  Revise thumb     .............     1,590.53            3       510.00  .............       102.00
                tendon.
26492........  Tendon transfer  .............     1,590.53            3       510.00  .............       102.00
                with graft.
26494........  Hand tendon/     .............     1,590.53            3       510.00  .............       102.00
                muscle
                transfer.
26496........  Revise thumb     .............     1,590.53            3       510.00  .............       102.00
                tendon.
26497........  Finger tendon    .............     1,590.53            3       510.00  .............       102.00
                transfer.
26498........  Finger tendon    .............     1,590.53            4       630.00  .............       126.00
                transfer.
26499........  Revision of      .............     1,590.53            3       510.00  .............       102.00
                finger.
26500........  Hand tendon      .............       992.95            4       630.00  .............       126.00
                reconstruction.
26502........  Hand tendon      .............     1,590.53            4       630.00  .............       126.00
                reconstruction.
26504........  Hand tendon      D............  ...........            4       630.00  .............  ...........
                reconstruction.
26508........  Release thumb    .............       992.95            3       510.00  .............       102.00
                contracture.
26510........  Thumb tendon     .............     1,590.53            3       510.00  .............       102.00
                transfer.
26516........  Fusion of        .............     1,590.53            1       333.00  .............        66.60
                knuckle joint.
26517........  Fusion of        .............     1,590.53            3       510.00  .............       102.00
                knuckle joints.
26518........  Fusion of        .............     1,590.53            3       510.00  .............       102.00
                knuckle joints.
26520........  Release knuckle  .............       992.95            3       510.00  .............       102.00
                contracture.
26525........  Release finger   .............       992.95            3       510.00  .............       102.00
                contracture.
26530........  Revise knuckle   .............     2,056.14            3       510.00  .............       102.00
                joint.
26531........  Revise knuckle   .............     2,915.91            7       995.00  .............       199.00
                with implant.
26535........  Revise finger    .............     2,056.14            5       717.00  .............       143.40
                joint.
26536........  Revise/implant   .............     2,915.91            5       717.00  .............       143.40
                finger joint.
26540........  Repair hand      .............       992.95            4       630.00  .............       126.00
                joint.
26541........  Repair hand      .............     1,590.53            7       995.00  .............       199.00
                joint with
                graft.
26542........  Repair hand      .............       992.95            4       630.00  .............       126.00
                joint with
                graft.
26545........  Reconstruct      .............     1,590.53            4       630.00  .............       126.00
                finger joint.
26546........  Repair nonunion  .............     1,590.53            4       630.00  .............       126.00
                hand.
26548........  Reconstruct      .............     1,590.53            4       630.00  .............       126.00
                finger joint.
26550........  Construct thumb  .............     1,590.53            2       446.00  .............        89.20
                replacement.
26555........  Positional       .............     1,590.53            3       510.00  .............       102.00
                change of
                finger.
26560........  Repair of web    .............       992.95            2       446.00  .............        89.20
                finger.
26561........  Repair of web    .............     1,590.53            3       510.00  .............       102.00
                finger.
26562........  Repair of web    .............     1,590.53            4       630.00  .............       126.00
                finger.
26565........  Correct          .............     1,590.53            5       717.00  .............       143.40
                metacarpal
                flaw.
26567........  Correct finger   .............     1,590.53            5       717.00  .............       143.40
                deformity.
26568........  Lengthen         .............     1,590.53            3       510.00  .............       102.00
                metacarpal/
                finger.
26580........  Repair hand      .............       992.95            5       717.00  .............       143.40
                deformity.
26587........  Reconstruct      .............       992.95            5       717.00  .............       143.40
                extra finger.
26590........  Repair finger    .............       992.95            5       717.00  .............       143.40
                deformity.
26591........  Repair muscles   .............     1,590.53            3       510.00  .............       102.00
                of hand.
26593........  Release muscles  .............       992.95            3       510.00  .............       102.00
                of hand.
26596........  Excision         .............       992.95            2       446.00  .............        89.20
                constricting
                tissue.
26605........  Treat            .............       103.62            2       103.62  Y............        20.72
                metacarpal
                fracture.
26607........  Treat            .............       103.62            2       103.62  Y............        20.72
                metacarpal
                fracture.
26608........  Treat            .............     1,569.06            4       630.00  .............       126.00
                metacarpal
                fracture.

[[Page 68256]]

 
26615........  Treat            .............     2,307.40            4       630.00  .............       126.00
                metacarpal
                fracture.
26645........  Treat thumb      .............       103.62            1       103.62  Y............        20.72
                fracture.
26650........  Treat thumb      .............     1,569.06            2       446.00  .............        89.20
                fracture.
26665........  Treat thumb      .............     2,307.40            4       630.00  .............       126.00
                fracture.
26675........  Treat hand       .............       103.62            2       103.62  Y............        20.72
                dislocation.
26676........  Pin hand         .............     1,569.06            2       446.00  .............        89.20
                dislocation.
26685........  Treat hand       .............     2,307.40            3       510.00  .............       102.00
                dislocation.
26686........  Treat hand       .............     3,517.03            3       510.00  .............       102.00
                dislocation.
26705........  Treat knuckle    .............       103.62            2       103.62  Y............        20.72
                dislocation.
26706........  Pin knuckle      .............       103.62            2       103.62  Y............        20.72
                dislocation.
26715........  Treat knuckle    .............     2,307.40            4       630.00  .............       126.00
                dislocation.
26727........  Treat finger     .............     1,569.06            7       995.00  .............       199.00
                fracture, each.
26735........  Treat finger     .............     2,307.40            4       630.00  .............       126.00
                fracture, each.
26742........  Treat finger     .............       103.62            2       103.62  Y............        20.72
                fracture, each.
26746........  Treat finger     .............     2,307.40            5       717.00  .............       143.40
                fracture, each.
26756........  Pin finger       .............     1,569.06            2       446.00  .............        89.20
                fracture, each.
26765........  Treat finger     .............     2,307.40            4       630.00  .............       126.00
                fracture, each.
26776........  Pin finger       .............     1,569.06            2       446.00  .............        89.20
                dislocation.
26785........  Treat finger     .............     1,569.06            2       446.00  .............        89.20
                dislocation.
26820........  Thumb fusion     .............     1,590.53            5       717.00  .............       143.40
                with graft.
26841........  Fusion of thumb  .............     1,590.53            4       630.00  .............       126.00
26842........  Thumb fusion     .............     1,590.53            4       630.00  .............       126.00
                with graft.
26843........  Fusion of hand   .............     1,590.53            3       510.00  .............       102.00
                joint.
26844........  Fusion/graft of  .............     1,590.53            3       510.00  .............       102.00
                hand joint.
26850........  Fusion of        .............     1,590.53            4       630.00  .............       126.00
                knuckle.
26852........  Fusion of        .............     1,590.53            4       630.00  .............       126.00
                knuckle with
                graft.
26860........  Fusion of        .............     1,590.53            3       510.00  .............       102.00
                finger joint.
26861........  Fusion of        .............     1,590.53            2       446.00  .............        89.20
                finger jnt,
                add-on.
26862........  Fusion/graft of  .............     1,590.53            4       630.00  .............       126.00
                finger joint.
26863........  Fuse/graft       .............     1,590.53            3       510.00  .............       102.00
                added joint.
26910........  Amputate         .............     1,590.53            3       510.00  .............       102.00
                metacarpal
                bone.
26951........  Amputation of    .............       992.95            2       446.00  .............        89.20
                finger/thumb.
26952........  Amputation of    .............       992.95            4       630.00  .............       126.00
                finger/thumb.
26990........  Drainage of      .............     1,282.87            1       333.00  .............        66.60
                pelvis lesion.
26991........  Drainage of      .............     1,282.87            1       333.00  .............        66.60
                pelvis bursa.
27000........  Incision of hip  .............     1,282.87            2       446.00  .............        89.20
                tendon.
27001........  Incision of hip  .............     1,544.67            3       510.00  .............       102.00
                tendon.
27003........  Incision of hip  .............     1,544.67            3       510.00  .............       102.00
                tendon.
27033........  Exploration of   .............     2,525.68            3       510.00  .............       102.00
                hip joint.
27035........  Denervation of   .............     2,525.68            4       630.00  .............       126.00
                hip joint.
27040........  Biopsy of soft   .............       418.49            1       333.00  .............        66.60
                tissues.
27041........  Biopsy of soft   .............       418.49            2       418.49  Y............        83.70
                tissues.
27047........  Remove hip/      .............     1,233.39            2       446.00  .............        89.20
                pelvis lesion.
27048........  Remove hip/      .............     1,233.39            3       510.00  .............       102.00
                pelvis lesion.
27049........  Remove tumor,    .............     1,233.39            3       510.00  .............       102.00
                hip/pelvis.
27050........  Biopsy of        .............     1,282.87            3       510.00  .............       102.00
                sacroiliac
                joint.
27052........  Biopsy of hip    .............     1,282.87            3       510.00  .............       102.00
                joint.
27060........  Removal of       .............     1,282.87            5       717.00  .............       143.40
                ischial bursa.
27062........  Remove femur     .............     1,282.87            5       717.00  .............       143.40
                lesion/bursa.
27065........  Removal of hip   .............     1,282.87            5       717.00  .............       143.40
                bone lesion.
27066........  Removal of hip   .............     1,544.67            5       717.00  .............       143.40
                bone lesion.
27067........  Remove/graft     .............     1,544.67            5       717.00  .............       143.40
                hip bone
                lesion.
27080........  Removal of tail  .............     1,544.67            2       446.00  .............        89.20
                bone.
27086........  Remove hip       .............       418.49            1       333.00  .............        66.60
                foreign body.
27087........  Remove hip       .............     1,282.87            3       510.00  .............       102.00
                foreign body.
27097........  Revision of hip  .............     1,544.67            3       510.00  .............       102.00
                tendon.
27098........  Transfer tendon  .............     1,544.67            3       510.00  .............       102.00
                to pelvis.
27100........  Transfer of      .............     2,525.68            4       630.00  .............       126.00
                abdominal
                muscle.
27105........  Transfer of      .............     2,525.68            4       630.00  .............       126.00
                spinal muscle.
27110........  Transfer of      .............     2,525.68            4       630.00  .............       126.00
                iliopsoas
                muscle.
27111........  Transfer of      .............     2,525.68            4       630.00  .............       126.00
                iliopsoas
                muscle.
27193........  Treat pelvic     .............       103.62            1       103.62  Y............        20.72
                ring fracture.
27194........  Treat pelvic     .............       897.11            2       446.00  .............        89.20
                ring fracture.
27202........  Treat tail bone  .............     2,307.40            2       446.00  .............        89.20
                fracture.
27230........  Treat thigh      .............       103.62            1       103.62  Y............        20.72
                fracture.

[[Page 68257]]

 
27238........  Treat thigh      .............       103.62            1       103.62  Y............        20.72
                fracture.
27246........  Treat thigh      .............       103.62            1       103.62  Y............        20.72
                fracture.
27250........  Treat hip        .............       103.62            1       103.62  Y............        20.72
                dislocation.
27252........  Treat hip        .............       897.11            2       446.00  .............        89.20
                dislocation.
27257........  Treat hip        .............       897.11            3       510.00  .............       102.00
                dislocation.
27265........  Treat hip        .............       103.62            1       103.62  Y............        20.72
                dislocation.
27266........  Treat hip        .............       897.11            2       446.00  .............        89.20
                dislocation.
27275........  Manipulation of  .............       897.11            2       446.00  .............        89.20
                hip joint.
27301........  Drain thigh/     .............     1,076.22            3       510.00  .............       102.00
                knee lesion.
27305........  Incise thigh     .............     1,282.87            2       446.00  .............        89.20
                tendon &
                fascia.
27306........  Incision of      .............     1,282.87            3       510.00  .............       102.00
                thigh tendon.
27307........  Incision of      .............     1,282.87            3       510.00  .............       102.00
                thigh tendons.
27310........  Exploration of   .............     1,544.67            4       630.00  .............       126.00
                knee joint.
27315........  Partial          D............  ...........            2       446.00  .............  ...........
                removal, thigh
                nerve.
27320........  Partial          D............  ...........            2       446.00  .............  ...........
                removal, thigh
                nerve.
27323........  Biopsy, thigh    .............       418.49            1       333.00  .............        66.60
                soft tissues.
27324........  Biopsy, thigh    .............     1,233.39            1       333.00  .............        66.60
                soft tissues.
27325........  Neurectomy,      A............     1,097.20            2       446.00  .............        89.20
                hamstring.
27326........  Neurectomy,      A............     1,097.20            2       446.00  .............        89.20
                popliteal.
27327........  Removal of       .............     1,233.39            2       446.00  .............        89.20
                thigh lesion.
27328........  Removal of       .............     1,233.39            3       510.00  .............       102.00
                thigh lesion.
27329........  Remove tumor,    .............     1,233.39            4       630.00  .............       126.00
                thigh/knee.
27330........  Biopsy, knee     .............     1,544.67            4       630.00  .............       126.00
                joint lining.
27331........  Explore/treat    .............     1,544.67            4       630.00  .............       126.00
                knee joint.
27332........  Removal of knee  .............     1,544.67            4       630.00  .............       126.00
                cartilage.
27333........  Removal of knee  .............     1,544.67            4       630.00  .............       126.00
                cartilage.
27334........  Remove knee      .............     1,544.67            4       630.00  .............       126.00
                joint lining.
27335........  Remove knee      .............     1,544.67            4       630.00  .............       126.00
                joint lining.
27340........  Removal of       .............     1,282.87            3       510.00  .............       102.00
                kneecap bursa.
27345........  Removal of knee  .............     1,282.87            4       630.00  .............       126.00
                cyst.
27347........  Remove knee      .............     1,282.87            4       630.00  .............       126.00
                cyst.
27350........  Removal of       .............     1,544.67            4       630.00  .............       126.00
                kneecap.
27355........  Remove femur     .............     1,544.67            3       510.00  .............       102.00
                lesion.
27356........  Remove femur     .............     1,544.67            4       630.00  .............       126.00
                lesion/graft.
27357........  Remove femur     .............     1,544.67            5       717.00  .............       143.40
                lesion/graft.
27358........  Remove femur     .............     1,544.67            5       717.00  .............       143.40
                lesion/
                fixation.
27360........  Partial          .............     1,544.67            5       717.00  .............       143.40
                removal, leg
                bone(s).
27372........  Removal of       .............     1,233.39            7       995.00  .............       199.00
                foreign body.
27380........  Repair of        .............     1,282.87            1       333.00  .............        66.60
                kneecap tendon.
27381........  Repair/graft     .............     1,282.87            3       510.00  .............       102.00
                kneecap tendon.
27385........  Repair of thigh  .............     1,282.87            3       510.00  .............       102.00
                muscle.
27386........  Repair/graft of  .............     1,282.87            3       510.00  .............       102.00
                thigh muscle.
27390........  Incision of      .............     1,282.87            1       333.00  .............        66.60
                thigh tendon.
27391........  Incision of      .............     1,282.87            2       446.00  .............        89.20
                thigh tendons.
27392........  Incision of      .............     1,282.87            3       510.00  .............       102.00
                thigh tendons.
27393........  Lengthening of   .............     1,544.67            2       446.00  .............        89.20
                thigh tendon.
27394........  Lengthening of   .............     1,544.67            3       510.00  .............       102.00
                thigh tendons.
27395........  Lengthening of   .............     2,525.68            3       510.00  .............       102.00
                thigh tendons.
27396........  Transplant of    .............     1,544.67            3       510.00  .............       102.00
                thigh tendon.
27397........  Transplants of   .............     2,525.68            3       510.00  .............       102.00
                thigh tendons.
27400........  Revise thigh     .............     2,525.68            3       510.00  .............       102.00
                muscles/
                tendons.
27403........  Repair of knee   .............     1,544.67            4       630.00  .............       126.00
                cartilage.
27405........  Repair of knee   .............     2,525.68            4       630.00  .............       126.00
                ligament.
27407........  Repair of knee   .............     4,092.54            4       630.00  .............       126.00
                ligament.
27409........  Repair of knee   .............     2,525.68            4       630.00  .............       126.00
                ligaments.
27418........  Repair           .............     2,525.68            3       510.00  .............       102.00
                degenerated
                kneecap.
27420........  Revision of      .............     2,525.68            3       510.00  .............       102.00
                unstable
                kneecap.
27422........  Revision of      .............     2,525.68            7       995.00  .............       199.00
                unstable
                kneecap.
27424........  Revision/        .............     2,525.68            3       510.00  .............       102.00
                removal of
                kneecap.
27425........  Lat retinacular  .............     1,544.67            7       995.00  .............       199.00
                release open.
27427........  Reconstruction,  .............     2,525.68            3       510.00  .............       102.00
                knee.
27428........  Reconstruction,  .............     4,092.54            4       630.00  .............       126.00
                knee.
27429........  Reconstruction,  .............     4,092.54            4       630.00  .............       126.00
                knee.
27430........  Revision of      .............     2,525.68            4       630.00  .............       126.00
                thigh muscles.
27435........  Incision of      .............     2,525.68            4       630.00  .............       126.00
                knee joint.

[[Page 68258]]

 
27437........  Revise kneecap.  .............     2,056.14            4       630.00  .............       126.00
27438........  Revise kneecap   .............     2,915.91            5       717.00  .............       143.40
                with implant.
27441........  Revision of      .............     2,056.14            5       717.00  .............       143.40
                knee joint.
27442........  Revision of      .............     2,056.14            5       717.00  .............       143.40
                knee joint.
27443........  Revision of      .............     2,056.14            5       717.00  .............       143.40
                knee joint.
27496........  Decompression    .............     1,282.87            5       717.00  .............       143.40
                of thigh/knee.
27497........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of thigh/knee.
27498........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of thigh/knee.
27499........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of thigh/knee.
27500........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                thigh fracture.
27501........  Treatment of     .............       103.62            2       103.62  Y............        20.72
                thigh fracture.
27502........  Treatment of     .............       103.62            2       103.62  Y............        20.72
                thigh fracture.
27503........  Treatment of     .............       103.62            3       103.62  Y............        20.72
                thigh fracture.
27508........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                thigh fracture.
27509........  Treatment of     .............     1,569.06            3       510.00  .............       102.00
                thigh fracture.
27510........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                thigh fracture.
27516........  Treat thigh fx   .............       103.62            1       103.62  Y............        20.72
                growth plate.
27517........  Treat thigh fx   .............       103.62            1       103.62  Y............        20.72
                growth plate.
27520........  Treat kneecap    .............       103.62            1       103.62  Y............        20.72
                fracture.
27530........  Treat knee       .............       103.62            1       103.62  Y............        20.72
                fracture.
27532........  Treat knee       .............       103.62            1       103.62  Y............        20.72
                fracture.
27538........  Treat knee       .............       103.62            1       103.62  Y............        20.72
                fracture(s).
27550........  Treat knee       .............       103.62            1       103.62  Y............        20.72
                dislocation.
27552........  Treat knee       .............       897.11            1       333.00  .............        66.60
                dislocation.
27560........  Treat kneecap    .............       103.62            1       103.62  Y............        20.72
                dislocation.
27562........  Treat kneecap    .............       897.11            1       333.00  .............        66.60
                dislocation.
27566........  Treat kneecap    .............     2,307.40            2       446.00  .............        89.20
                dislocation.
27570........  Fixation of      .............       897.11            1       333.00  .............        66.60
                knee joint.
27594........  Amputation       .............     1,282.87            3       510.00  .............       102.00
                follow-up
                surgery.
27600........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of lower leg.
27601........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of lower leg.
27602........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of lower leg.
27603........  Drain lower leg  .............     1,076.22            2       446.00  .............        89.20
                lesion.
27604........  Drain lower leg  .............     1,282.87            2       446.00  .............        89.20
                bursa.
27605........  Incision of      .............     1,255.56            1       333.00  .............        66.60
                achilles
                tendon.
27606........  Incision of      .............     1,282.87            1       333.00  .............        66.60
                achilles
                tendon.
27607........  Treat lower leg  .............     1,282.87            2       446.00  .............        89.20
                bone lesion.
27610........  Explore/treat    .............     1,544.67            2       446.00  .............        89.20
                ankle joint.
27612........  Exploration of   .............     1,544.67            3       510.00  .............       102.00
                ankle joint.
27614........  Biopsy lower     .............     1,233.39            2       446.00  .............        89.20
                leg soft
                tissue.
27615........  Remove tumor,    .............     1,544.67            3       510.00  .............       102.00
                lower leg.
27618........  Remove lower     .............       928.31            2       446.00  .............        89.20
                leg lesion.
27619........  Remove lower     .............     1,233.39            3       510.00  .............       102.00
                leg lesion.
27620........  Explore/treat    .............     1,544.67            4       630.00  .............       126.00
                ankle joint.
27625........  Remove ankle     .............     1,544.67            4       630.00  .............       126.00
                joint lining.
27626........  Remove ankle     .............     1,544.67            4       630.00  .............       126.00
                joint lining.
27630........  Removal of       .............     1,282.87            3       510.00  .............       102.00
                tendon lesion.
27635........  Remove lower     .............     1,544.67            3       510.00  .............       102.00
                leg bone
                lesion.
27637........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                leg bone
                lesion.
27638........  Remove/graft     .............     1,544.67            3       510.00  .............       102.00
                leg bone
                lesion.
27640........  Partial removal  .............     2,525.68            2       446.00  .............        89.20
                of tibia.
27641........  Partial removal  .............     1,544.67            2       446.00  .............        89.20
                of fibula.
27647........  Extensive ankle/ .............     2,525.68            3       510.00  .............       102.00
                heel surgery.
27650........  Repair achilles  .............     2,525.68            3       510.00  .............       102.00
                tendon.
27652........  Repair/graft     .............     4,092.54            3       510.00  .............       102.00
                achilles
                tendon.
27654........  Repair of        .............     2,525.68            3       510.00  .............       102.00
                achilles
                tendon.
27656........  Repair leg       .............     1,282.87            2       446.00  .............        89.20
                fascia defect.
27658........  Repair of leg    .............     1,282.87            1       333.00  .............        66.60
                tendon, each.
27659........  Repair of leg    .............     1,282.87            2       446.00  .............        89.20
                tendon, each.
27664........  Repair of leg    .............     1,282.87            2       446.00  .............        89.20
                tendon, each.
27665........  Repair of leg    .............     1,544.67            2       446.00  .............        89.20
                tendon, each.
27675........  Repair lower     .............     1,282.87            2       446.00  .............        89.20
                leg tendons.
27676........  Repair lower     .............     1,544.67            3       510.00  .............       102.00
                leg tendons.
27680........  Release of       .............     1,544.67            3       510.00  .............       102.00
                lower leg
                tendon.
27681........  Release of       .............     1,544.67            2       446.00  .............        89.20
                lower leg
                tendons.

[[Page 68259]]

 
27685........  Revision of      .............     1,544.67            3       510.00  .............       102.00
                lower leg
                tendon.
27686........  Revise lower     .............     1,544.67            3       510.00  .............       102.00
                leg tendons.
27687........  Revision of      .............     1,544.67            3       510.00  .............       102.00
                calf tendon.
27690........  Revise lower     .............     2,525.68            4       630.00  .............       126.00
                leg tendon.
27691........  Revise lower     .............     2,525.68            4       630.00  .............       126.00
                leg tendon.
27692........  Revise           .............     2,525.68            3       510.00  .............       102.00
                additional leg
                tendon.
27695........  Repair of ankle  .............     1,544.67            2       446.00  .............        89.20
                ligament.
27696........  Repair of ankle  .............     1,544.67            2       446.00  .............        89.20
                ligaments.
27698........  Repair of ankle  .............     1,544.67            2       446.00  .............        89.20
                ligament.
27700........  Revision of      .............     2,056.14            5       717.00  .............       143.40
                ankle joint.
27704........  Removal of       .............     1,282.87            2       446.00  .............        89.20
                ankle implant.
27705........  Incision of      .............     2,525.68            2       446.00  .............        89.20
                tibia.
27707........  Incision of      .............     1,282.87            2       446.00  .............        89.20
                fibula.
27709........  Incision of      .............     1,544.67            2       446.00  .............        89.20
                tibia & fibula.
27730........  Repair of tibia  .............     1,544.67            2       446.00  .............        89.20
                epiphysis.
27732........  Repair of        .............     1,544.67            2       446.00  .............        89.20
                fibula
                epiphysis.
27734........  Repair lower     .............     1,544.67            2       446.00  .............        89.20
                leg epiphyses.
27740........  Repair of leg    .............     1,544.67            2       446.00  .............        89.20
                epiphyses.
27742........  Repair of leg    .............     2,525.68            2       446.00  .............        89.20
                epiphyses.
27745........  Reinforce tibia  .............     4,092.54            3       510.00  .............       102.00
27750........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                tibia fracture.
27752........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                tibia fracture.
27756........  Treatment of     .............     1,569.06            3       510.00  .............       102.00
                tibia fracture.
27758........  Treatment of     .............     2,307.40            4       630.00  .............       126.00
                tibia fracture.
27759........  Treatment of     .............     3,517.03            4       630.00  .............       126.00
                tibia fracture.
27760........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27762........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27766........  Treatment of     .............     2,307.40            3       510.00  .............       102.00
                ankle fracture.
27780........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                fibula
                fracture.
27781........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                fibula
                fracture.
27784........  Treatment of     .............     2,307.40            3       510.00  .............       102.00
                fibula
                fracture.
27786........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27788........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27792........  Treatment of     .............     2,307.40            3       510.00  .............       102.00
                ankle fracture.
27808........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27810........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27814........  Treatment of     .............     2,307.40            3       510.00  .............       102.00
                ankle fracture.
27816........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27818........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                ankle fracture.
27822........  Treatment of     .............     2,307.40            3       510.00  .............       102.00
                ankle fracture.
27823........  Treatment of     .............     3,517.03            3       510.00  .............       102.00
                ankle fracture.
27824........  Treat lower leg  .............       103.62            1       103.62  Y............        20.72
                fracture.
27825........  Treat lower leg  .............       103.62            2       103.62  Y............        20.72
                fracture.
27826........  Treat lower leg  .............     2,307.40            3       510.00  .............       102.00
                fracture.
27827........  Treat lower leg  .............     3,517.03            3       510.00  .............       102.00
                fracture.
27828........  Treat lower leg  .............     3,517.03            4       630.00  .............       126.00
                fracture.
27829........  Treat lower leg  .............     2,307.40            2       446.00  .............        89.20
                joint.
27830........  Treat lower leg  .............       103.62            1       103.62  Y............        20.72
                dislocation.
27831........  Treat lower leg  .............       103.62            1       103.62  Y............        20.72
                dislocation.
27832........  Treat lower leg  .............     2,307.40            2       446.00  .............        89.20
                dislocation.
27840........  Treat ankle      .............       103.62            1       103.62  Y............        20.72
                dislocation.
27842........  Treat ankle      .............       897.11            1       333.00  .............        66.60
                dislocation.
27846........  Treat ankle      .............     2,307.40            3       510.00  .............       102.00
                dislocation.
27848........  Treat ankle      .............     2,307.40            3       510.00  .............       102.00
                dislocation.
27860........  Fixation of      .............       897.11            1       333.00  .............        66.60
                ankle joint.
27870........  Fusion of ankle  .............     4,092.54            4       630.00  .............       126.00
                joint, open.
27871........  Fusion of        .............     4,092.54            4       630.00  .............       126.00
                tibiofibular
                joint.
27884........  Amputation       .............     1,282.87            3       510.00  .............       102.00
                follow-up
                surgery.
27889........  Amputation of    .............     1,544.67            3       510.00  .............       102.00
                foot at ankle.
27892........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of leg.
27893........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of leg.
27894........  Decompression    .............     1,282.87            3       510.00  .............       102.00
                of leg.
28002........  Treatment of     .............     1,282.87            3       510.00  .............       102.00
                foot infection.
28003........  Treatment of     .............     1,282.87            3       510.00  .............       102.00
                foot infection.
28005........  Treat foot bone  .............     1,255.56            3       510.00  .............       102.00
                lesion.

[[Page 68260]]

 
28008........  Incision of      .............     1,255.56            3       510.00  .............       102.00
                foot fascia.
28011........  Incision of toe  .............     1,255.56            3       510.00  .............       102.00
                tendons.
28020........  Exploration of   .............     1,255.56            2       446.00  .............        89.20
                foot joint.
28022........  Exploration of   .............     1,255.56            2       446.00  .............        89.20
                foot joint.
28024........  Exploration of   .............     1,255.56            2       446.00  .............        89.20
                toe joint.
28030........  Removal of foot  D............  ...........            4       630.00  .............  ...........
                nerve.
28035........  Decompression    .............     1,097.20            4       630.00  .............       126.00
                of tibia nerve.
28043........  Excision of      .............     1,233.39            2       446.00  .............        89.20
                foot lesion.
28045........  Excision of      .............     1,255.56            3       510.00  .............       102.00
                foot lesion.
28046........  Resection of     .............     1,255.56            3       510.00  .............       102.00
                tumor, foot.
28050........  Biopsy of foot   .............     1,255.56            2       446.00  .............        89.20
                joint lining.
28052........  Biopsy of foot   .............     1,255.56            2       446.00  .............        89.20
                joint lining.
28054........  Biopsy of toe    .............     1,255.56            2       446.00  .............        89.20
                joint lining.
28055........  Neurectomy,      A............     1,097.20            4       630.00  .............       126.00
                foot.
28060........  Partial          .............     1,255.56            2       446.00  .............        89.20
                removal, foot
                fascia.
28062........  Removal of foot  .............     1,255.56            3       510.00  .............       102.00
                fascia.
28070........  Removal of foot  .............     1,255.56            3       510.00  .............       102.00
                joint lining.
28072........  Removal of foot  .............     1,255.56            3       510.00  .............       102.00
                joint lining.
28080........  Removal of foot  .............     1,255.56            3       510.00  .............       102.00
                lesion.
28086........  Excise foot      .............     1,255.56            2       446.00  .............        89.20
                tendon sheath.
28088........  Excise foot      .............     1,255.56            2       446.00  .............        89.20
                tendon sheath.
28090........  Removal of foot  .............     1,255.56            3       510.00  .............       102.00
                lesion.
28092........  Removal of toe   .............     1,255.56            3       510.00  .............       102.00
                lesions.
28100........  Removal of       .............     1,255.56            2       446.00  .............        89.20
                ankle/heel
                lesion.
28102........  Remove/graft     .............     2,511.33            3       510.00  .............       102.00
                foot lesion.
28103........  Remove/graft     .............     2,511.33            3       510.00  .............       102.00
                foot lesion.
28104........  Removal of foot  .............     1,255.56            2       446.00  .............        89.20
                lesion.
28106........  Remove/graft     .............     2,511.33            3       510.00  .............       102.00
                foot lesion.
28107........  Remove/graft     .............     2,511.33            3       510.00  .............       102.00
                foot lesion.
28108........  Removal of toe   .............     1,255.56            2       446.00  .............        89.20
                lesions.
28110........  Part removal of  .............     1,255.56            3       510.00  .............       102.00
                metatarsal.
28111........  Part removal of  .............     1,255.56            3       510.00  .............       102.00
                metatarsal.
28112........  Part removal of  .............     1,255.56            3       510.00  .............       102.00
                metatarsal.
28113........  Part removal of  .............     1,255.56            3       510.00  .............       102.00
                metatarsal.
28114........  Removal of       .............     1,255.56            3       510.00  .............       102.00
                metatarsal
                heads.
28116........  Revision of      .............     1,255.56            3       510.00  .............       102.00
                foot.
28118........  Removal of heel  .............     1,255.56            4       630.00  .............       126.00
                bone.
28119........  Removal of heel  .............     1,255.56            4       630.00  .............       126.00
                spur.
28120........  Part removal of  .............     1,255.56            7       995.00  .............       199.00
                ankle/heel.
28122........  Partial removal  .............     1,255.56            3       510.00  .............       102.00
                of foot bone.
28126........  Partial removal  .............     1,255.56            3       510.00  .............       102.00
                of toe.
28130........  Removal of       .............     1,255.56            3       510.00  .............       102.00
                ankle bone.
28140........  Removal of       .............     1,255.56            3       510.00  .............       102.00
                metatarsal.
28150........  Removal of toe.  .............     1,255.56            3       510.00  .............       102.00
28153........  Partial removal  .............     1,255.56            3       510.00  .............       102.00
                of toe.
28160........  Partial removal  .............     1,255.56            3       510.00  .............       102.00
                of toe.
28171........  Extensive foot   .............     1,255.56            3       510.00  .............       102.00
                surgery.
28173........  Extensive foot   .............     1,255.56            3       510.00  .............       102.00
                surgery.
28175........  Extensive foot   .............     1,255.56            3       510.00  .............       102.00
                surgery.
28192........  Removal of foot  .............       928.31            2       446.00  .............        89.20
                foreign body.
28193........  Removal of foot  .............       418.49            4       418.49  Y............        83.70
                foreign body.
28200........  Repair of foot   .............     1,255.56            3       510.00  .............       102.00
                tendon.
28202........  Repair/graft of  .............     1,255.56            3       510.00  .............       102.00
                foot tendon.
28208........  Repair of foot   .............     1,255.56            3       510.00  .............       102.00
                tendon.
28210........  Repair/graft of  .............     2,511.33            3       510.00  .............       102.00
                foot tendon.
28222........  Release of foot  .............     1,255.56            1       333.00  .............        66.60
                tendons.
28225........  Release of foot  .............     1,255.56            1       333.00  .............        66.60
                tendon.
28226........  Release of foot  .............     1,255.56            1       333.00  .............        66.60
                tendons.
28234........  Incision of      .............     1,255.56            2       446.00  .............        89.20
                foot tendon.
28238........  Revision of      .............     2,511.33            3       510.00  .............       102.00
                foot tendon.
28240........  Release of big   .............     1,255.56            2       446.00  .............        89.20
                toe.
28250........  Revision of      .............     1,255.56            3       510.00  .............       102.00
                foot fascia.
28260........  Release of       .............     1,255.56            3       510.00  .............       102.00
                midfoot joint.
28261........  Revision of      .............     1,255.56            3       510.00  .............       102.00
                foot tendon.
28262........  Revision of      .............     1,255.56            4       630.00  .............       126.00
                foot and ankle.

[[Page 68261]]

 
28264........  Release of       .............     2,511.33            1       333.00  .............        66.60
                midfoot joint.
28270........  Release of foot  .............     1,255.56            3       510.00  .............       102.00
                contracture.
28280........  Fusion of toes.  .............     1,255.56            2       446.00  .............        89.20
28285........  Repair of        .............     1,255.56            3       510.00  .............       102.00
                hammertoe.
28286........  Repair of        .............     1,255.56            4       630.00  .............       126.00
                hammertoe.
28288........  Partial removal  .............     1,255.56            3       510.00  .............       102.00
                of foot bone.
28289........  Repair hallux    .............     1,255.56            3       510.00  .............       102.00
                rigidus.
28290........  Correction of    .............     1,735.54            2       446.00  .............        89.20
                bunion.
28292........  Correction of    .............     1,735.54            2       446.00  .............        89.20
                bunion.
28293........  Correction of    .............     1,735.54            3       510.00  .............       102.00
                bunion.
28294........  Correction of    .............     1,735.54            3       510.00  .............       102.00
                bunion.
28296........  Correction of    .............     1,735.54            3       510.00  .............       102.00
                bunion.
28297........  Correction of    .............     1,735.54            3       510.00  .............       102.00
                bunion.
28298........  Correction of    .............     1,735.54            3       510.00  .............       102.00
                bunion.
28299........  Correction of    .............     1,735.54            5       717.00  .............       143.40
                bunion.
28300........  Incision of      .............     2,511.33            2       446.00  .............        89.20
                heel bone.
28302........  Incision of      .............     1,255.56            2       446.00  .............        89.20
                ankle bone.
28304........  Incision of      .............     2,511.33            2       446.00  .............        89.20
                midfoot bones.
28305........  Incise/graft     .............     2,511.33            3       510.00  .............       102.00
                midfoot bones.
28306........  Incision of      .............     1,255.56            4       630.00  .............       126.00
                metatarsal.
28307........  Incision of      .............     1,255.56            4       630.00  .............       126.00
                metatarsal.
28308........  Incision of      .............     1,255.56            2       446.00  .............        89.20
                metatarsal.
28309........  Incision of      .............     2,511.33            4       630.00  .............       126.00
                metatarsals.
28310........  Revision of big  .............     1,255.56            3       510.00  .............       102.00
                toe.
28312........  Revision of toe  .............     1,255.56            3       510.00  .............       102.00
28313........  Repair           .............     1,255.56            2       446.00  .............        89.20
                deformity of
                toe.
28315........  Removal of       .............     1,255.56            4       630.00  .............       126.00
                sesamoid bone.
28320........  Repair of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28322........  Repair of        .............     2,511.33            4       630.00  .............       126.00
                metatarsals.
28340........  Resect enlarged  .............     1,255.56            4       630.00  .............       126.00
                toe tissue.
28341........  Resect enlarged  .............     1,255.56            4       630.00  .............       126.00
                toe.
28344........  Repair extra     .............     1,255.56            4       630.00  .............       126.00
                toe(s).
28345........  Repair webbed    .............     1,255.56            4       630.00  .............       126.00
                toe(s).
28400........  Treatment of     .............       103.62            1       103.62  Y............        20.72
                heel fracture.
28405........  Treatment of     .............       103.62            2       103.62  Y............        20.72
                heel fracture.
28406........  Treatment of     .............     1,569.06            2       446.00  .............        89.20
                heel fracture.
28415........  Treat heel       .............     2,307.40            3       510.00  .............       102.00
                fracture.
28420........  Treat/graft      .............     2,307.40            4       630.00  .............       126.00
                heel fracture.
28435........  Treatment of     .............       103.62            2       103.62  Y............        20.72
                ankle fracture.
28436........  Treatment of     .............     1,569.06            2       446.00  .............        89.20
                ankle fracture.
28445........  Treat ankle      .............     2,307.40            3       510.00  .............       102.00
                fracture.
28456........  Treat midfoot    .............     1,569.06            2       446.00  .............        89.20
                fracture.
28465........  Treat midfoot    .............     2,307.40            3       510.00  .............       102.00
                fracture, each.
28476........  Treat            .............     1,569.06            2       446.00  .............        89.20
                metatarsal
                fracture.
28485........  Treat            .............     2,307.40            4       630.00  .............       126.00
                metatarsal
                fracture.
28496........  Treat big toe    .............     1,569.06            2       446.00  .............        89.20
                fracture.
28505........  Treat big toe    .............     2,307.40            3       510.00  .............       102.00
                fracture.
28525........  Treat toe        .............     2,307.40            3       510.00  .............       102.00
                fracture.
28531........  Treat sesamoid   .............     2,307.40            3       510.00  .............       102.00
                bone fracture.
28545........  Treat foot       .............     1,569.06            1       333.00  .............        66.60
                dislocation.
28546........  Treat foot       .............     1,569.06            2       446.00  .............        89.20
                dislocation.
28555........  Repair foot      .............     2,307.40            2       446.00  .............        89.20
                dislocation.
28575........  Treat foot       .............       103.62            1       103.62  Y............        20.72
                dislocation.
28576........  Treat foot       .............     1,569.06            3       510.00  .............       102.00
                dislocation.
28585........  Repair foot      .............     2,307.40            3       510.00  .............       102.00
                dislocation.
28605........  Treat foot       .............       103.62            1       103.62  Y............        20.72
                dislocation.
28606........  Treat foot       .............     1,569.06            2       446.00  .............        89.20
                dislocation.
28615........  Repair foot      .............     2,307.40            3       510.00  .............       102.00
                dislocation.
28635........  Treat toe        .............       897.11            1       333.00  .............        66.60
                dislocation.
28636........  Treat toe        .............     1,569.06            3       510.00  .............       102.00
                dislocation.
28645........  Repair toe       .............     2,307.40            3       510.00  .............       102.00
                dislocation.
28665........  Treat toe        .............       897.11            1       333.00  .............        66.60
                dislocation.
28666........  Treat toe        .............     1,569.06            3       510.00  .............       102.00
                dislocation.
28675........  Repair of toe    .............     2,307.40            3       510.00  .............       102.00
                dislocation.
28705........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.

[[Page 68262]]

 
28715........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28725........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28730........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28735........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28737........  Revision of      .............     2,511.33            5       717.00  .............       143.40
                foot bones.
28740........  Fusion of foot   .............     2,511.33            4       630.00  .............       126.00
                bones.
28750........  Fusion of big    .............     2,511.33            4       630.00  .............       126.00
                toe joint.
28755........  Fusion of big    .............     1,255.56            4       630.00  .............       126.00
                toe joint.
28760........  Fusion of big    .............     2,511.33            4       630.00  .............       126.00
                toe joint.
28810........  Amputation toe   .............     1,255.56            2       446.00  .............        89.20
                & metatarsal.
28820........  Amputation of    .............     1,255.56            2       446.00  .............        89.20
                toe.
28825........  Partial          .............     1,255.56            2       446.00  .............        89.20
                amputation of
                toe.
29800........  Jaw arthroscopy/ .............     1,759.49            3       510.00  .............       102.00
                surgery.
29804........  Jaw arthroscopy/ .............     1,759.49            3       510.00  .............       102.00
                surgery.
29805........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy,
                dx.
29806........  Shoulder         .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29807........  Shoulder         .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29819........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29820........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29821........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29822........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29823........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29824........  Shoulder         .............     1,759.49            5       717.00  .............       143.40
                arthroscopy/
                surgery.
29825........  Shoulder         .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29826........  Shoulder         .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29827........  Arthroscop       .............     2,796.96            5       717.00  .............       143.40
                rotator cuff
                repr.
29830........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy.
29834........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29835........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29836........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29837........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29838........  Elbow            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29840........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy.
29843........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29844........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29845........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29846........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29847........  Wrist            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29848........  Wrist endoscopy/ .............     1,759.49            9     1,339.00  .............       267.80
                surgery.
29850........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29851........  Knee             .............     2,796.96            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29855........  Tibial           .............     2,796.96            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29856........  Tibial           .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29860........  Hip              .............     1,759.49            4       630.00  .............       126.00
                arthroscopy,
                dx.
29861........  Hip arthroscopy/ .............     1,759.49            4       630.00  .............       126.00
                surgery.
29862........  Hip arthroscopy/ .............     2,796.96            9     1,339.00  .............       267.80
                surgery.
29863........  Hip arthroscopy/ .............     2,796.96            4       630.00  .............       126.00
                surgery.
29870........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy,
                dx.
29871........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                drainage.
29873........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29874........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29875........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29876........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29877........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29879........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29880........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29881........  Knee             .............     1,759.49            4       630.00  .............       126.00
                arthroscopy/
                surgery.
29882........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29883........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29884........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29885........  Knee             .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29886........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29887........  Knee             .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29888........  Knee             .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29889........  Knee             .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.

[[Page 68263]]

 
29891........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29892........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29893........  Scope, plantar   .............     1,255.56            9     1,255.56  Y............       251.11
                fasciotomy.
29894........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29895........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29897........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29898........  Ankle            .............     1,759.49            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29899........  Ankle            .............     2,796.96            3       510.00  .............       102.00
                arthroscopy/
                surgery.
29900........  Mcp joint        .............       992.95            3       510.00  .............       102.00
                arthroscopy,
                dx.
29901........  Mcp joint        .............       992.95            3       510.00  .............       102.00
                arthroscopy,
                surg.
29902........  Mcp joint        .............       992.95            3       510.00  .............       102.00
                arthroscopy,
                surg.
30115........  Removal of nose  .............     1,009.71            2       446.00  .............        89.20
                polyp(s).
30117........  Removal of       .............     1,009.71            3       510.00  .............       102.00
                intranasal
                lesion.
30118........  Removal of       .............     1,434.04            3       510.00  .............       102.00
                intranasal
                lesion.
30120........  Revision of      .............     1,009.71            1       333.00  .............        66.60
                nose.
30125........  Removal of nose  .............     2,348.02            2       446.00  .............        89.20
                lesion.
30130........  Excise inferior  .............     1,009.71            3       510.00  .............       102.00
                turbinate.
30140........  Resect inferior  .............     1,434.04            2       446.00  .............        89.20
                turbinate.
30150........  Partial removal  .............     2,348.02            3       510.00  .............       102.00
                of nose.
30160........  Removal of nose  .............     2,348.02            4       630.00  .............       126.00
30220........  Insert nasal     .............       464.15            3       464.15  Y............        92.83
                septal button.
30310........  Remove nasal     .............     1,009.71            1       333.00  .............        66.60
                foreign body.
30320........  Remove nasal     .............     1,009.71            2       446.00  .............        89.20
                foreign body.
30400........  Reconstruction   .............     2,348.02            4       630.00  .............       126.00
                of nose.
30410........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of nose.
30420........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of nose.
30430........  Revision of      .............     1,434.04            3       510.00  .............       102.00
                nose.
30435........  Revision of      .............     2,348.02            5       717.00  .............       143.40
                nose.
30450........  Revision of      .............     2,348.02            7       995.00  .............       199.00
                nose.
30460........  Revision of      .............     2,348.02            7       995.00  .............       199.00
                nose.
30462........  Revision of      .............     2,348.02            9     1,339.00  .............       267.80
                nose.
30465........  Repair nasal     .............     2,348.02            9     1,339.00  .............       267.80
                stenosis.
30520........  Repair of nasal  .............     1,434.04            4       630.00  .............       126.00
                septum.
30540........  Repair nasal     .............     2,348.02            5       717.00  .............       143.40
                defect.
30545........  Repair nasal     .............     2,348.02            5       717.00  .............       143.40
                defect.
30560........  Release of       .............       150.72            2       150.72  Y............        30.14
                nasal
                adhesions.
30580........  Repair upper     .............     2,348.02            4       630.00  .............       126.00
                jaw fistula.
30600........  Repair mouth/    .............     2,348.02            4       630.00  .............       126.00
                nose fistula.
30620........  Intranasal       .............     2,348.02            7       995.00  .............       199.00
                reconstruction.
30630........  Repair nasal     .............     1,434.04            7       995.00  .............       199.00
                septum defect.
30801........  Ablate inf       .............       464.15            1       333.00  .............        66.60
                turbinate,
                superf.
30802........  Cauterization,   .............       464.15            1       333.00  .............        66.60
                inner nose.
30903........  Control of       .............        72.48            1        72.48  Y............        14.50
                nosebleed.
30905........  Control of       .............        72.48            1        72.48  Y............        14.50
                nosebleed.
30906........  Repeat control   .............        72.48            1        72.48  Y............        14.50
                of nosebleed.
30915........  Ligation, nasal  .............     1,529.38            2       446.00  .............        89.20
                sinus artery.
30920........  Ligation, upper  .............     1,529.38            3       510.00  .............       102.00
                jaw artery.
30930........  Ther fx, nasal   .............     1,009.71            4       630.00  .............       126.00
                inf turbinate.
31020........  Exploration,     .............     1,434.04            2       446.00  .............        89.20
                maxillary
                sinus.
31030........  Exploration,     .............     2,348.02            3       510.00  .............       102.00
                maxillary
                sinus.
31032........  Explore sinus,   .............     2,348.02            4       630.00  .............       126.00
                remove polyps.
31050........  Exploration,     .............     2,348.02            2       446.00  .............        89.20
                sphenoid sinus.
31051........  Sphenoid sinus   .............     2,348.02            4       630.00  .............       126.00
                surgery.
31070........  Exploration of   .............     1,434.04            2       446.00  .............        89.20
                frontal sinus.
31075........  Exploration of   .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31080........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31081........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31084........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31085........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31086........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31087........  Removal of       .............     2,348.02            4       630.00  .............       126.00
                frontal sinus.
31090........  Exploration of   .............     2,348.02            5       717.00  .............       143.40
                sinuses.
31200........  Removal of       .............     2,348.02            2       446.00  .............        89.20
                ethmoid sinus.
31201........  Removal of       .............     2,348.02            5       717.00  .............       143.40
                ethmoid sinus.
31205........  Removal of       .............     2,348.02            3       510.00  .............       102.00
                ethmoid sinus.

[[Page 68264]]

 
31233........  Nasal/sinus      .............        86.39            2        86.39  Y............        17.28
                endoscopy, dx.
31235........  Nasal/sinus      .............       909.28            1       333.00  .............        66.60
                endoscopy, dx.
31237........  Nasal/sinus      .............       909.28            2       446.00  .............        89.20
                endoscopy,
                surg.
31238........  Nasal/sinus      .............       909.28            1       333.00  .............        66.60
                endoscopy,
                surg.
31239........  Nasal/sinus      .............     1,349.30            4       630.00  .............       126.00
                endoscopy,
                surg.
31240........  Nasal/sinus      .............       909.28            2       446.00  .............        89.20
                endoscopy,
                surg.
31254........  Revision of      .............     1,349.30            3       510.00  .............       102.00
                ethmoid sinus.
31255........  Removal of       .............     1,349.30            5       717.00  .............       143.40
                ethmoid sinus.
31256........  Exploration      .............     1,349.30            3       510.00  .............       102.00
                maxillary
                sinus.
31267........  Endoscopy,       .............     1,349.30            3       510.00  .............       102.00
                maxillary
                sinus.
31276........  Sinus            .............     1,349.30            3       510.00  .............       102.00
                endoscopy,
                surgical.
31287........  Nasal/sinus      .............     1,349.30            3       510.00  .............       102.00
                endoscopy,
                surg.
31288........  Nasal/sinus      .............     1,349.30            3       510.00  .............       102.00
                endoscopy,
                surg.
31300........  Removal of       .............     1,434.04            5       717.00  .............       143.40
                larynx lesion.
31320........  Diagnostic       .............     2,348.02            2       446.00  .............        89.20
                incision,
                larynx.
31400........  Revision of      .............     2,348.02            2       446.00  .............        89.20
                larynx.
31420........  Removal of       .............     2,348.02            2       446.00  .............        89.20
                epiglottis.
31510........  Laryngoscopy     .............       909.28            2       446.00  .............        89.20
                with biopsy.
31511........  Remove foreign   .............        86.39            2        86.39  Y............        17.28
                body, larynx.
31512........  Removal of       .............       909.28            2       446.00  .............        89.20
                larynx lesion.
31513........  Injection into   .............        86.39            2        86.39  Y............        17.28
                vocal cord.
31515........  Laryngoscopy     .............       909.28            1       333.00  .............        66.60
                for aspiration.
31525........  Dx laryngoscopy  .............       909.28            1       333.00  .............        66.60
                excl nb.
31526........  Dx laryngoscopy  .............     1,349.30            2       446.00  .............        89.20
                w/oper scope.
31527........  Laryngoscopy     .............     1,349.30            1       333.00  .............        66.60
                for treatment.
31528........  Laryngoscopy     .............       909.28            2       446.00  .............        89.20
                and dilation.
31529........  Laryngoscopy     .............       909.28            2       446.00  .............        89.20
                and dilation.
31530........  Laryngoscopy w/  .............     1,349.30            2       446.00  .............        89.20
                fb removal.
31531........  Laryngoscopy w/  .............     1,349.30            3       510.00  .............       102.00
                fb & op scope.
31535........  Laryngoscopy w/  .............     1,349.30            2       446.00  .............        89.20
                biopsy.
31536........  Laryngoscopy w/  .............     1,349.30            3       510.00  .............       102.00
                bx & op scope.
31540........  Laryngoscopy w/  .............     1,349.30            3       510.00  .............       102.00
                exc of tumor.
31541........  Larynscop w/     .............     1,349.30            4       630.00  .............       126.00
                tumr exc +
                scope.
31545........  Remove vc        .............     1,349.30            4       630.00  .............       126.00
                lesion w/scope.
31546........  Remove vc        .............     1,349.30            4       630.00  .............       126.00
                lesion scope/
                graft.
31560........  Laryngoscop w/   .............     1,349.30            5       717.00  .............       143.40
                arytenoidectom.
31561........  Larynscop,       .............     1,349.30            5       717.00  .............       143.40
                remve cart +
                scop.
31570........  Laryngoscope w/  .............       909.28            2       446.00  .............        89.20
                vc inj.
31571........  Laryngoscop w/   .............     1,349.30            2       446.00  .............        89.20
                vc inj + scope.
31576........  Laryngoscopy     .............     1,349.30            2       446.00  .............        89.20
                with biopsy.
31577........  Remove foreign   .............       236.42            2       236.42  Y............        47.28
                body, larynx.
31578........  Removal of       .............     1,349.30            2       446.00  .............        89.20
                larynx lesion.
31580........  Revision of      .............     2,348.02            5       717.00  .............       143.40
                larynx.
31582........  Revision of      .............     2,348.02            5       717.00  .............       143.40
                larynx.
31588........  Revision of      .............     2,348.02            5       717.00  .............       143.40
                larynx.
31590........  Reinnervate      .............     2,348.02            5       717.00  .............       143.40
                larynx.
31595........  Larynx nerve     .............     2,348.02            2       446.00  .............        89.20
                surgery.
31603........  Incision of      .............       464.15            1       333.00  .............        66.60
                windpipe.
31611........  Surgery/speech   .............     1,434.04            3       510.00  .............       102.00
                prosthesis.
31612........  Puncture/clear   .............     1,434.04            1       333.00  .............        66.60
                windpipe.
31613........  Repair windpipe  .............     1,434.04            2       446.00  .............        89.20
                opening.
31614........  Repair windpipe  .............     2,348.02            2       446.00  .............        89.20
                opening.
31615........  Visualization    .............       585.35            1       333.00  .............        66.60
                of windpipe.
31620........  Endobronchial    A*...........     1,984.52            1       333.00  .............        66.60
                us add-on.
31622........  Dx bronchoscope/ .............       585.35            1       333.00  .............        66.60
                wash.
31623........  Dx bronchoscope/ .............       585.35            2       446.00  .............        89.20
                brush.
31624........  Dx bronchoscope/ .............       585.35            2       446.00  .............        89.20
                lavage.
31625........  Bronchoscopy w/  .............       585.35            2       446.00  .............        89.20
                biopsy(s).
31628........  Bronchoscopy/    .............       585.35            2       446.00  .............        89.20
                lung bx, each.
31629........  Bronchoscopy/    .............       585.35            2       446.00  .............        89.20
                needle bx,
                each.
31630........  Bronchoscopy     .............     1,352.90            2       446.00  .............        89.20
                dilate/fx repr.
31631........  Bronchoscopy,    .............     1,352.90            2       446.00  .............        89.20
                dilate w/stent.
31635........  Bronchoscopy w/  .............       585.35            2       446.00  .............        89.20
                fb removal.
31636........  Bronchoscopy,    .............     1,352.90            2       446.00  .............        89.20
                bronch stents.
31637........  Bronchoscopy,    .............       585.35            1       333.00  .............        66.60
                stent add-on.

[[Page 68265]]

 
31638........  Bronchoscopy,    .............     1,352.90            2       446.00  .............        89.20
                revise stent.
31640........  Bronchoscopy w/  .............     1,352.90            2       446.00  .............        89.20
                tumor excise.
31641........  Bronchoscopy,    .............     1,352.90            2       446.00  .............        89.20
                treat blockage.
31643........  Diag             .............       585.35            2       446.00  .............        89.20
                bronchoscope/
                catheter.
31645........  Bronchoscopy,    .............       585.35            1       333.00  .............        66.60
                clear airways.
31646........  Bronchoscopy,    .............       585.35            1       333.00  .............        66.60
                reclear airway.
31656........  Bronchoscopy,    .............       585.35            1       333.00  .............        66.60
                inj for x-ray.
31700........  Insertion of     D............  ...........            1       333.00  .............  ...........
                airway
                catheter.
31717........  Bronchial brush  .............       236.42            1       236.42  Y............        47.28
                biopsy.
31720........  Clearance of     .............        47.32            1        47.32  Y............         9.46
                airways.
31730........  Intro, windpipe  .............       236.42            1       236.42  Y............        47.28
                wire/tube.
31750........  Repair of        .............     2,348.02            5       717.00  .............       143.40
                windpipe.
31755........  Repair of        .............     2,348.02            2       446.00  .............        89.20
                windpipe.
31820........  Closure of       .............     1,009.71            1       333.00  .............        66.60
                windpipe
                lesion.
31825........  Repair of        .............     1,434.04            2       446.00  .............        89.20
                windpipe
                defect.
31830........  Revise windpipe  .............     1,434.04            2       446.00  .............        89.20
                scar.
32000........  Drainage of      .............       222.78            1       222.78  Y............        44.56
                chest.
32400........  Needle biopsy    .............       377.32            1       333.00  .............        66.60
                chest lining.
32405........  Biopsy, lung or  .............       377.32            1       333.00  .............        66.60
                mediastinum.
32420........  Puncture/clear   .............       222.78            1       222.78  Y............        44.56
                lung.
33010........  Drainage of      .............       222.78            2       222.78  Y............        44.56
                heart sac.
33011........  Repeat drainage  .............       222.78            2       222.78  Y............        44.56
                of heart sac.
33212........  Insertion of     .............     6,042.45            3       510.00  .............       102.00
                pulse
                generator.
33213........  Insertion of     .............     6,931.86            3       510.00  .............       102.00
                pulse
                generator.
33222........  Revise pocket,   .............     1,317.27            2       446.00  .............        89.20
                pacemaker.
33223........  Revise pocket,   .............     1,317.27            2       446.00  .............        89.20
                pacing-defib.
33233........  Removal of       .............     1,574.45            2       446.00  .............        89.20
                pacemaker
                system.
35188........  Repair blood     .............     2,319.75            4       630.00  .............       126.00
                vessel lesion.
35207........  Repair blood     .............     2,319.75            4       630.00  .............       126.00
                vessel lesion.
35875........  Removal of clot  .............     2,319.75            9     1,339.00  .............       267.80
                in graft.
35876........  Removal of clot  .............     2,319.75            9     1,339.00  .............       267.80
                in graft.
36260........  Insertion of     .............     1,752.03            3       510.00  .............       102.00
                infusion pump.
36261........  Revision of      .............     1,752.03            2       446.00  .............        89.20
                infusion pump.
36262........  Removal of       .............     1,393.26            1       333.00  .............        66.60
                infusion pump.
36475........  Endovenous rf,   .............     2,134.71            9     1,339.00  .............       267.80
                1st vein.
36476........  Endovenous rf,   .............     2,134.71            9     1,339.00  .............       267.80
                vein add-on.
36478........  Endovenous       .............     1,529.38            9     1,339.00  .............       267.80
                laser, 1st
                vein.
36479........  Endovenous       .............     1,529.38            9     1,339.00  .............       267.80
                laser vein
                addon.
36555........  Insert non-      .............       539.97            1       333.00  .............        66.60
                tunnel cv cath.
36556........  Insert non-      .............       539.97            1       333.00  .............        66.60
                tunnel cv cath.
36557........  Insert tunneled  .............     1,393.26            2       446.00  .............        89.20
                cv cath.
36558........  Insert tunneled  .............     1,393.26            2       446.00  .............        89.20
                cv cath.
36560........  Insert tunneled  .............     1,752.03            3       510.00  .............       102.00
                cv cath.
36561........  Insert tunneled  .............     1,752.03            3       510.00  .............       102.00
                cv cath.
36563........  Insert tunneled  .............     1,752.03            3       510.00  .............       102.00
                cv cath.
36565........  Insert tunneled  .............     1,752.03            3       510.00  .............       102.00
                cv cath.
36566........  Insert tunneled  .............     5,130.17            3       510.00  .............       102.00
                cv cath.
36568........  Insert picc      .............       539.97            1       333.00  .............        66.60
                cath.
36569........  Insert picc      .............       539.97            1       333.00  .............        66.60
                cath.
36570........  Insert picvad    .............     1,393.26            3       510.00  .............       102.00
                cath.
36571........  Insert picvad    .............     1,393.26            3       510.00  .............       102.00
                cath.
36575........  Repair tunneled  .............       539.97            2       446.00  .............        89.20
                cv cath.
36576........  Repair tunneled  .............       539.97            2       446.00  .............        89.20
                cv cath.
36578........  Replace          .............     1,393.26            2       446.00  .............        89.20
                tunneled cv
                cath.
36580........  Replace cvad     .............       539.97            1       333.00  .............        66.60
                cath.
36581........  Replace          .............     1,393.26            2       446.00  .............        89.20
                tunneled cv
                cath.
36582........  Replace          .............     1,752.03            3       510.00  .............       102.00
                tunneled cv
                cath.
36583........  Replace          .............     1,752.03            3       510.00  .............       102.00
                tunneled cv
                cath.
36584........  Replace picc     .............       539.97            1       333.00  .............        66.60
                cath.
36585........  Replace picvad   .............     1,393.26            3       510.00  .............       102.00
                cath.
36589........  Removal          .............       539.97            1       333.00  .............        66.60
                tunneled cv
                cath.
36590........  Removal          .............       539.97            1       333.00  .............        66.60
                tunneled cv
                cath.
36640........  Insertion        .............     1,752.03            1       333.00  .............        66.60
                catheter,
                artery.
36800........  Insertion of     .............     1,795.68            3       510.00  .............       102.00
                cannula.
36810........  Insertion of     .............     1,795.68            3       510.00  .............       102.00
                cannula.

[[Page 68266]]

 
36815........  Insertion of     .............     1,795.68            3       510.00  .............       102.00
                cannula.
36818........  Av fuse, uppr    A*...........     2,319.75            3       510.00  .............       102.00
                arm, cephalic.
36819........  Av fuse, uppr    .............     2,319.75            3       510.00  .............       102.00
                arm, basilic.
36820........  Av fusion/       .............     2,319.75            3       510.00  .............       102.00
                forearm vein.
36821........  Av fusion        .............     2,319.75            3       510.00  .............       102.00
                direct any
                site.
36825........  Artery-vein      .............     2,319.75            4       630.00  .............       126.00
                autograft.
36830........  Artery-vein      .............     2,319.75            4       630.00  .............       126.00
                nonautograft.
36831........  Open thrombect   .............     2,319.75            9     1,339.00  .............       267.80
                av fistula.
36832........  Av fistula       .............     2,319.75            4       630.00  .............       126.00
                revision, open.
36833........  Av fistula       .............     2,319.75            4       630.00  .............       126.00
                revision.
36834........  Repair A-V       .............     2,319.75            3       510.00  .............       102.00
                aneurysm.
36835........  Artery to vein   .............     1,795.68            4       630.00  .............       126.00
                shunt.
36860........  External         .............       127.40            2       127.40  Y............        25.48
                cannula
                declotting.
36861........  Cannula          .............     1,795.68            3       510.00  .............       102.00
                declotting.
36870........  Percut           .............     1,990.44            9     1,339.00  .............       267.80
                thrombect av
                fistula.
37500........  Endoscopy        .............     2,134.71            3       510.00  .............       102.00
                ligate perf
                veins.
37607........  Ligation of a-v  .............     1,529.38            3       510.00  .............       102.00
                fistula.
37609........  Temporal artery  .............       928.31            2       446.00  .............        89.20
                procedure.
37650........  Revision of      .............     1,529.38            2       446.00  .............        89.20
                major vein.
37700........  Revise leg vein  .............     2,134.71            2       446.00  .............        89.20
37718........  Ligate/strip     .............     2,134.71            3       510.00  .............       102.00
                short leg vein.
37722........  Ligate/strip     .............     2,134.71            3       510.00  .............       102.00
                long leg vein.
37735........  Removal of leg   .............     2,134.71            3       510.00  .............       102.00
                veins/lesion.
37760........  Ligation, leg    .............     1,529.38            3       510.00  .............       102.00
                veins, open.
37780........  Revision of leg  .............     1,529.38            3       510.00  .............       102.00
                vein.
37785........  Ligate/divide/   .............     1,529.38            3       510.00  .............       102.00
                excise vein.
37790........  Penile venous    .............     2,027.66            3       510.00  .............       102.00
                occlusion.
38300........  Drainage, lymph  .............       685.58            1       333.00  .............        66.60
                node lesion.
38305........  Drainage, lymph  .............     1,076.22            2       446.00  .............        89.20
                node lesion.
38308........  Incision of      .............     1,306.94            2       446.00  .............        89.20
                lymph channels.
38500........  Biopsy/removal,  .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
38505........  Needle biopsy,   .............       240.00            1       240.00  Y............        48.00
                lymph nodes.
38510........  Biopsy/removal,  .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
38520........  Biopsy/removal,  .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
38525........  Biopsy/removal,  .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
38530........  Biopsy/removal,  .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
38542........  Explore deep     .............     2,318.72            2       446.00  .............        89.20
                node(s), neck.
38550........  Removal, neck/   .............     1,306.94            3       510.00  .............       102.00
                armpit lesion.
38555........  Removal, neck/   .............     1,306.94            4       630.00  .............       126.00
                armpit lesion.
38570........  Laparoscopy,     .............     2,676.86            9     1,339.00  .............       267.80
                lymph node
                biop.
38571........  Laparoscopy,     .............     4,333.90            9     1,339.00  .............       267.80
                lymphadenectom
                y.
38572........  Laparoscopy,     .............     2,676.86            9     1,339.00  .............       267.80
                lymphadenectom
                y.
38740........  Remove armpit    .............     2,318.72            2       446.00  .............        89.20
                lymph nodes.
38745........  Remove armpit    .............     2,318.72            4       630.00  .............       126.00
                lymph nodes.
38760........  Remove groin     .............     1,306.94            2       446.00  .............        89.20
                lymph nodes.
40500........  Partial          .............     1,009.71            2       446.00  .............        89.20
                excision of
                lip.
40510........  Partial          .............     1,434.04            2       446.00  .............        89.20
                excision of
                lip.
40520........  Partial          .............     1,009.71            2       446.00  .............        89.20
                excision of
                lip.
40525........  Reconstruct lip  .............     1,434.04            2       446.00  .............        89.20
                with flap.
40527........  Reconstruct lip  .............     1,434.04            2       446.00  .............        89.20
                with flap.
40530........  Partial removal  .............     1,434.04            2       446.00  .............        89.20
                of lip.
40650........  Repair lip.....  .............       464.15            3       464.15  Y............        92.83
40652........  Repair lip.....  .............       464.15            3       464.15  Y............        92.83
40654........  Repair lip.....  .............       464.15            3       464.15  Y............        92.83
40700........  Repair cleft     .............     2,348.02            7       995.00  .............       199.00
                lip/nasal.
40701........  Repair cleft     .............     2,348.02            7       995.00  .............       199.00
                lip/nasal.
40720........  Repair cleft     .............     2,348.02            7       995.00  .............       199.00
                lip/nasal.
40761........  Repair cleft     .............     2,348.02            3       510.00  .............       102.00
                lip/nasal.
40801........  Drainage of      .............       464.15            2       446.00  .............        89.20
                mouth lesion.
40814........  Excise/repair    .............     1,009.71            2       446.00  .............        89.20
                mouth lesion.
40816........  Excision of      .............     1,434.04            2       446.00  .............        89.20
                mouth lesion.
40818........  Excise oral      .............       150.72            1       150.72  Y............        30.14
                mucosa for
                graft.
40819........  Excise lip or    .............       464.15            1       333.00  .............        66.60
                cheek fold.
40831........  Repair mouth     .............       464.15            1       333.00  .............        66.60
                laceration.
40840........  Reconstruction   .............     1,434.04            2       446.00  .............        89.20
                of mouth.

[[Page 68267]]

 
40842........  Reconstruction   .............     1,434.04            3       510.00  .............       102.00
                of mouth.
40843........  Reconstruction   .............     1,434.04            3       510.00  .............       102.00
                of mouth.
40844........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of mouth.
40845........  Reconstruction   .............     2,348.02            5       717.00  .............       143.40
                of mouth.
41005........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                mouth lesion.
41006........  Drainage of      .............     1,434.04            1       333.00  .............        66.60
                mouth lesion.
41007........  Drainage of      .............     1,009.71            1       333.00  .............        66.60
                mouth lesion.
41008........  Drainage of      .............     1,009.71            1       333.00  .............        66.60
                mouth lesion.
41009........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                mouth lesion.
41010........  Incision of      .............       464.15            1       333.00  .............        66.60
                tongue fold.
41015........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                mouth lesion.
41016........  Drainage of      .............       464.15            1       333.00  .............        66.60
                mouth lesion.
41017........  Drainage of      .............       464.15            1       333.00  .............        66.60
                mouth lesion.
41018........  Drainage of      .............       464.15            1       333.00  .............        66.60
                mouth lesion.
41112........  Excision of      .............     1,009.71            2       446.00  .............        89.20
                tongue lesion.
41113........  Excision of      .............     1,009.71            2       446.00  .............        89.20
                tongue lesion.
41114........  Excision of      .............     1,434.04            2       446.00  .............        89.20
                tongue lesion.
41116........  Excision of      .............     1,009.71            1       333.00  .............        66.60
                mouth lesion.
41120........  Partial removal  .............     1,434.04            5       717.00  .............       143.40
                of tongue.
41250........  Repair tongue    .............       150.72            2       150.72  Y............        30.14
                laceration.
41251........  Repair tongue    .............       150.72            2       150.72  Y............        30.14
                laceration.
41252........  Repair tongue    .............       464.15            2       446.00  .............        89.20
                laceration.
41500........  Fixation of      .............     1,434.04            1       333.00  .............        66.60
                tongue.
41510........  Tongue to lip    .............     1,009.71            1       333.00  .............        66.60
                surgery.
41520........  Reconstruction,  .............       464.15            2       446.00  .............        89.20
                tongue fold.
41800........  Drainage of gum  .............        88.46            1        88.46  Y............        17.69
                lesion.
41827........  Excision of gum  .............     1,434.04            2       446.00  .............        89.20
                lesion.
42000........  Drainage mouth   .............       150.72            2       150.72  Y............        30.14
                roof lesion.
42107........  Excision         .............     1,434.04            2       446.00  .............        89.20
                lesion, mouth
                roof.
42120........  Remove palate/   .............     2,348.02            4       630.00  .............       126.00
                lesion.
42140........  Excision of      .............       464.15            2       446.00  .............        89.20
                uvula.
42145........  Repair palate,   .............     1,434.04            5       717.00  .............       143.40
                pharynx/uvula.
42180........  Repair palate..  .............       150.72            1       150.72  Y............        30.14
42182........  Repair palate..  .............     2,348.02            2       446.00  .............        89.20
42200........  Reconstruct      .............     2,348.02            5       717.00  .............       143.40
                cleft palate.
42205........  Reconstruct      .............     2,348.02            5       717.00  .............       143.40
                cleft palate.
42210........  Reconstruct      .............     2,348.02            5       717.00  .............       143.40
                cleft palate.
42215........  Reconstruct      .............     2,348.02            7       995.00  .............       199.00
                cleft palate.
42220........  Reconstruct      .............     2,348.02            5       717.00  .............       143.40
                cleft palate.
42226........  Lengthening of   .............     2,348.02            5       717.00  .............       143.40
                palate.
42235........  Repair palate..  .............     1,009.71            5       717.00  .............       143.40
42260........  Repair nose to   .............     1,434.04            4       630.00  .............       126.00
                lip fistula.
42300........  Drainage of      .............     1,009.71            1       333.00  .............        66.60
                salivary gland.
42305........  Drainage of      .............     1,009.71            2       446.00  .............        89.20
                salivary gland.
42310........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                salivary gland.
42320........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                salivary gland.
42340........  Removal of       .............     1,009.71            2       446.00  .............        89.20
                salivary stone.
42405........  Biopsy of        .............     1,009.71            2       446.00  .............        89.20
                salivary gland.
42408........  Excision of      .............     1,009.71            3       510.00  .............       102.00
                salivary cyst.
42409........  Drainage of      .............     1,009.71            3       510.00  .............       102.00
                salivary cyst.
42410........  Excise parotid   .............     2,348.02            3       510.00  .............       102.00
                gland/lesion.
42415........  Excise parotid   .............     2,348.02            7       995.00  .............       199.00
                gland/lesion.
42420........  Excise parotid   .............     2,348.02            7       995.00  .............       199.00
                gland/lesion.
42425........  Excise parotid   .............     2,348.02            7       995.00  .............       199.00
                gland/lesion.
42440........  Excise           .............     2,348.02            3       510.00  .............       102.00
                submaxillary
                gland.
42450........  Excise           .............     1,434.04            2       446.00  .............        89.20
                sublingual
                gland.
42500........  Repair salivary  .............     1,434.04            3       510.00  .............       102.00
                duct.
42505........  Repair salivary  .............     2,348.02            4       630.00  .............       126.00
                duct.
42507........  Parotid duct     .............     2,348.02            3       510.00  .............       102.00
                diversion.
42508........  Parotid duct     .............     2,348.02            4       630.00  .............       126.00
                diversion.
42509........  Parotid duct     .............     2,348.02            4       630.00  .............       126.00
                diversion.
42510........  Parotid duct     .............     2,348.02            4       630.00  .............       126.00
                diversion.
42600........  Closure of       .............     1,009.71            1       333.00  .............        66.60
                salivary
                fistula.
42665........  Ligation of      .............     1,434.04            7       995.00  .............       199.00
                salivary duct.
42700........  Drainage of      .............       150.72            1       150.72  Y............        30.14
                tonsil abscess.

[[Page 68268]]

 
42720........  Drainage of      .............     1,009.71            1       333.00  .............        66.60
                throat abscess.
42725........  Drainage of      .............     2,348.02            2       446.00  .............        89.20
                throat abscess.
42802........  Biopsy of        .............     1,009.71            1       333.00  .............        66.60
                throat.
42804........  Biopsy of upper  .............     1,009.71            1       333.00  .............        66.60
                nose/throat.
42806........  Biopsy of upper  .............     1,434.04            2       446.00  .............        89.20
                nose/throat.
42808........  Excise pharynx   .............     1,009.71            2       446.00  .............        89.20
                lesion.
42810........  Excision of      .............     1,434.04            3       510.00  .............       102.00
                neck cyst.
42815........  Excision of      .............     2,348.02            5       717.00  .............       143.40
                neck cyst.
42820........  Remove tonsils   .............     1,359.46            3       510.00  .............       102.00
                and adenoids.
42821........  Remove tonsils   .............     1,359.46            5       717.00  .............       143.40
                and adenoids.
42825........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                tonsils.
42826........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                tonsils.
42830........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                adenoids.
42831........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                adenoids.
42835........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                adenoids.
42836........  Removal of       .............     1,359.46            4       630.00  .............       126.00
                adenoids.
42860........  Excision of      .............     1,359.46            3       510.00  .............       102.00
                tonsil tags.
42870........  Excision of      .............     1,359.46            3       510.00  .............       102.00
                lingual tonsil.
42890........  Partial removal  .............     2,348.02            7       995.00  .............       199.00
                of pharynx.
42892........  Revision of      .............     2,348.02            7       995.00  .............       199.00
                pharyngeal
                walls.
42900........  Repair throat    .............       464.15            1       333.00  .............        66.60
                wound.
42950........  Reconstruction   .............     1,434.04            2       446.00  .............        89.20
                of throat.
42955........  Surgical         .............     1,434.04            2       446.00  .............        89.20
                opening of
                throat.
42960........  Control throat   .............        72.48            1        72.48  Y............        14.50
                bleeding.
42962........  Control throat   .............     2,348.02            2       446.00  .............        89.20
                bleeding.
42972........  Control nose/    .............     1,009.71            3       510.00  .............       102.00
                throat
                bleeding.
43200........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy.
43201........  Esoph scope w/   .............       511.26            1       333.00  .............        66.60
                submucous inj.
43202........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy,
                biopsy.
43204........  Esoph scope w/   .............       511.26            1       333.00  .............        66.60
                sclerosis inj.
43205........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy/
                ligation.
43215........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy.
43216........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy/
                lesion.
43217........  Esophagus        .............       511.26            1       333.00  .............        66.60
                endoscopy.
43219........  Esophagus        .............     1,410.54            1       333.00  .............        66.60
                endoscopy.
43220........  Esoph            .............       511.26            1       333.00  .............        66.60
                endoscopy,
                dilation.
43226........  Esoph            .............       511.26            1       333.00  .............        66.60
                endoscopy,
                dilation.
43227........  Esoph            .............       511.26            2       446.00  .............        89.20
                endoscopy,
                repair.
43228........  Esoph            .............     1,583.12            2       446.00  .............        89.20
                endoscopy,
                ablation.
43231........  Esoph endoscopy  .............       511.26            2       446.00  .............        89.20
                w/us exam.
43232........  Esoph endoscopy  .............       511.26            2       446.00  .............        89.20
                w/us fn bx.
43234........  Upper GI         .............       511.26            1       333.00  .............        66.60
                endoscopy,
                exam.
43235........  Uppr gi          .............       511.26            1       333.00  .............        66.60
                endoscopy,
                diagnosis.
43236........  Uppr gi scope w/ .............       511.26            2       446.00  .............        89.20
                submuc inj.
43237........  Endoscopic us    .............       511.26            2       446.00  .............        89.20
                exam, esoph.
43238........  Uppr gi          .............       511.26            2       446.00  .............        89.20
                endoscopy w/us
                fn bx.
43239........  Upper GI         .............       511.26            2       446.00  .............        89.20
                endoscopy,
                biopsy.
43240........  Esoph endoscope  .............       511.26            2       446.00  .............        89.20
                w/drain cyst.
43241........  Upper GI         .............       511.26            2       446.00  .............        89.20
                endoscopy with
                tube.
43242........  Uppr gi          .............       511.26            2       446.00  .............        89.20
                endoscopy w/us
                fn bx.
43243........  Upper gi         .............       511.26            2       446.00  .............        89.20
                endoscopy &
                inject.
43244........  Upper GI         .............       511.26            2       446.00  .............        89.20
                endoscopy/
                ligation.
43245........  Uppr gi scope    .............       511.26            2       446.00  .............        89.20
                dilate strictr.
43246........  Place            .............       511.26            2       446.00  .............        89.20
                gastrostomy
                tube.
43247........  Operative upper  .............       511.26            2       446.00  .............        89.20
                GI endoscopy.
43248........  Uppr gi          .............       511.26            2       446.00  .............        89.20
                endoscopy/
                guide wire.
43249........  Esoph            .............       511.26            2       446.00  .............        89.20
                endoscopy,
                dilation.
43250........  Upper GI         .............       511.26            2       446.00  .............        89.20
                endoscopy/
                tumor.
43251........  Operative upper  .............       511.26            2       446.00  .............        89.20
                GI endoscopy.
43255........  Operative upper  .............       511.26            2       446.00  .............        89.20
                GI endoscopy.
43256........  Uppr gi          .............     1,410.54            3       510.00  .............       102.00
                endoscopy w/
                stent.
43257........  Uppr gi scope w/ A*...........     1,583.12            3       510.00  .............       102.00
                thrml txmnt.
43258........  Operative upper  .............       511.26            3       510.00  .............       102.00
                GI endoscopy.
43259........  Endoscopic       .............       511.26            3       510.00  .............       102.00
                ultrasound
                exam.
43260........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.

[[Page 68269]]

 
43261........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43262........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43263........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43264........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43265........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43267........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43268........  Endo             .............     1,410.54            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43269........  Endo             .............     1,410.54            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43271........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43272........  Endo             .............     1,219.41            2       446.00  .............        89.20
                cholangiopancr
                eatograph.
43450........  Dilate           .............       335.41            1       333.00  .............        66.60
                esophagus.
43453........  Dilate           .............       335.41            1       333.00  .............        66.60
                esophagus.
43456........  Dilate           .............       335.41            2       335.41  Y............        67.08
                esophagus.
43458........  Dilate           .............       335.41            2       335.41  Y............        67.08
                esophagus.
43600........  Biopsy of        .............       511.26            1       333.00  .............        66.60
                stomach.
43653........  Laparoscopy,     .............     2,676.86            9     1,339.00  .............       267.80
                gastrostomy.
43750........  Place            .............       511.26            2       446.00  .............        89.20
                gastrostomy
                tube.
43760........  Change           .............       144.98            1       144.98  Y............        29.00
                gastrostomy
                tube.
43761........  Reposition       A*...........       459.78            1       333.00  .............        66.60
                gastrostomy
                tube.
43870........  Repair stomach   .............       511.26            1       333.00  .............        66.60
                opening.
44100........  Biopsy of bowel  .............       511.26            1       333.00  .............        66.60
44312........  Revision of      .............     1,317.27            1       333.00  .............        66.60
                ileostomy.
44340........  Revision of      .............     1,317.27            3       510.00  .............       102.00
                colostomy.
44360........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44361........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy/
                biopsy.
44363........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44364........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44365........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44366........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44369........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44370........  Small bowel      .............     1,410.54            9     1,339.00  .............       267.80
                endoscopy/
                stent.
44372........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44373........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44376........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44377........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy/
                biopsy.
44378........  Small bowel      .............       583.61            2       446.00  .............        89.20
                endoscopy.
44379........  Sbowel           .............     1,410.54            9     1,339.00  .............       267.80
                endoscope w/
                stent.
44380........  Small bowel      .............       583.61            1       333.00  .............        66.60
                endoscopy.
44382........  Small bowel      .............       583.61            1       333.00  .............        66.60
                endoscopy.
44383........  Ileoscopy w/     .............     1,410.54            9     1,339.00  .............       267.80
                stent.
44385........  Endoscopy of     .............       538.99            1       333.00  .............        66.60
                bowel pouch.
44386........  Endoscopy,       .............       538.99            1       333.00  .............        66.60
                bowel pouch/
                biop.
44388........  Colonoscopy....  .............       538.99            1       333.00  .............        66.60
44389........  Colonoscopy      .............       538.99            1       333.00  .............        66.60
                with biopsy.
44390........  Colonoscopy for  .............       538.99            1       333.00  .............        66.60
                foreign body.
44391........  Colonoscopy for  .............       538.99            1       333.00  .............        66.60
                bleeding.
44392........  Colonoscopy &    .............       538.99            1       333.00  .............        66.60
                polypectomy.
44393........  Colonoscopy,     .............       538.99            1       333.00  .............        66.60
                lesion removal.
44394........  Colonoscopy w/   .............       538.99            1       333.00  .............        66.60
                snare.
44397........  Colonoscopy w/   .............     1,410.54            1       333.00  .............        66.60
                stent.
45000........  Drainage of      .............       312.07            1       312.07  Y............        62.41
                pelvic abscess.
45005........  Drainage of      .............       783.03            2       446.00  .............        89.20
                rectal abscess.
45020........  Drainage of      .............       783.03            2       446.00  .............        89.20
                rectal abscess.
45100........  Biopsy of        .............     1,368.78            1       333.00  .............        66.60
                rectum.
45108........  Removal of       .............     1,368.78            2       446.00  .............        89.20
                anorectal
                lesion.
45150........  Excision of      .............     1,368.78            2       446.00  .............        89.20
                rectal
                stricture.
45160........  Excision of      .............     1,368.78            2       446.00  .............        89.20
                rectal lesion.
45170........  Excision of      .............     1,368.78            2       446.00  .............        89.20
                rectal lesion.
45190........  Destruction,     .............     1,368.78            9     1,339.00  .............       267.80
                rectal tumor.
45305........  Proctosigmoidos  .............       525.41            1       333.00  .............        66.60
                copy w/bx.
45307........  Proctosigmoidos  .............     1,268.55            1       333.00  .............        66.60
                copy fb.
45308........  Proctosigmoidos  .............       525.41            1       333.00  .............        66.60
                copy removal.
45309........  Proctosigmoidos  .............       525.41            1       333.00  .............        66.60
                copy removal.
45315........  Proctosigmoidos  .............       525.41            1       333.00  .............        66.60
                copy removal.
45317........  Proctosigmoidos  .............       525.41            1       333.00  .............        66.60
                copy bleed.

[[Page 68270]]

 
45320........  Proctosigmoidos  .............     1,268.55            1       333.00  .............        66.60
                copy ablate.
45321........  Proctosigmoidos  .............     1,268.55            1       333.00  .............        66.60
                copy volvul.
45327........  Proctosigmoidos  .............     1,410.54            1       333.00  .............        66.60
                copy w/stent.
45331........  Sigmoidoscopy    .............       299.24            1       299.24  Y............        59.85
                and biopsy.
45332........  Sigmoidoscopy w/ .............       299.24            1       299.24  Y............        59.85
                fb removal.
45333........  Sigmoidoscopy &  .............       525.41            1       333.00  .............        66.60
                polypectomy.
45334........  Sigmoidoscopy    .............       525.41            1       333.00  .............        66.60
                for bleeding.
45335........  Sigmoidoscopy w/ .............       299.24            1       299.24  Y............        59.85
                submuc inj.
45337........  Sigmoidoscopy &  .............       299.24            1       299.24  Y............        59.85
                decompress.
45338........  Sigmoidoscopy w/ .............       525.41            1       333.00  .............        66.60
                tumr remove.
45339........  Sigmoidoscopy w/ .............       525.41            1       333.00  .............        66.60
                ablate tumr.
45340........  Sig w/balloon    .............       525.41            1       333.00  .............        66.60
                dilation.
45341........  Sigmoidoscopy w/ .............       525.41            1       333.00  .............        66.60
                ultrasound.
45342........  Sigmoidoscopy w/ .............       525.41            1       333.00  .............        66.60
                us guide bx.
45345........  Sigmoidoscopy w/ .............     1,410.54            1       333.00  .............        66.60
                stent.
45355........  Surgical         .............       538.99            1       333.00  .............        66.60
                colonoscopy.
45378........  Diagnostic       .............       538.99            2       446.00  .............        89.20
                colonoscopy.
45379........  Colonoscopy w/   .............       538.99            2       446.00  .............        89.20
                fb removal.
45380........  Colonoscopy and  .............       538.99            2       446.00  .............        89.20
                biopsy.
45381........  Colonoscopy,     .............       538.99            2       446.00  .............        89.20
                submucous inj.
45382........  Colonoscopy/     .............       538.99            2       446.00  .............        89.20
                control
                bleeding.
45383........  Lesion removal   .............       538.99            2       446.00  .............        89.20
                colonoscopy.
45384........  Lesion remove    .............       538.99            2       446.00  .............        89.20
                colonoscopy.
45385........  Lesion removal   .............       538.99            2       446.00  .............        89.20
                colonoscopy.
45386........  Colonoscopy      .............       538.99            2       446.00  .............        89.20
                dilate
                stricture.
45387........  Colonoscopy w/   .............     1,410.54            1       333.00  .............        66.60
                stent.
45391........  Colonoscopy w/   .............       538.99            2       446.00  .............        89.20
                endoscope us.
45392........  Colonoscopy w/   .............       538.99            2       446.00  .............        89.20
                endoscopic fnb.
45500........  Repair of        .............     1,368.78            2       446.00  .............        89.20
                rectum.
45505........  Repair of        .............     1,820.61            2       446.00  .............        89.20
                rectum.
45560........  Repair of        .............     1,820.61            2       446.00  .............        89.20
                rectocele.
45900........  Reduction of     .............       312.07            1       312.07  Y............        62.41
                rectal
                prolapse.
45905........  Dilation of      .............     1,368.78            1       333.00  .............        66.60
                anal sphincter.
45910........  Dilation of      .............     1,368.78            1       333.00  .............        66.60
                rectal
                narrowing.
45915........  Remove rectal    .............       312.07            1       312.07  Y............        62.41
                obstruction.
45990........  Surg dx exam,    .............       312.07            2       312.07  Y............        62.41
                anorectal.
46020........  Placement of     .............     1,368.78            3       510.00  .............       102.00
                seton.
46030........  Removal of       .............       312.07            1       312.07  Y............        62.41
                rectal marker.
46040........  Incision of      .............     1,368.78            3       510.00  .............       102.00
                rectal abscess.
46045........  Incision of      .............     1,368.78            2       446.00  .............        89.20
                rectal abscess.
46050........  Incision of      .............       312.07            1       312.07  Y............        62.41
                anal abscess.
46060........  Incision of      .............     1,368.78            2       446.00  .............        89.20
                rectal abscess.
46080........  Incision of      .............     1,368.78            3       510.00  .............       102.00
                anal sphincter.
46200........  Removal of anal  .............     1,368.78            2       446.00  .............        89.20
                fissure.
46210........  Removal of anal  .............     1,368.78            2       446.00  .............        89.20
                crypt.
46211........  Removal of anal  .............     1,368.78            2       446.00  .............        89.20
                crypts.
46220........  Removal of anal  .............     1,368.78            1       333.00  .............        66.60
                tag.
46230........  Removal of anal  .............     1,368.78            1       333.00  .............        66.60
                tags.
46250........  Hemorrhoidectom  .............     1,368.78            3       510.00  .............       102.00
                y.
46255........  Hemorrhoidectom  .............     1,368.78            3       510.00  .............       102.00
                y.
46257........  Remove           .............     1,368.78            3       510.00  .............       102.00
                hemorrhoids &
                fissure.
46258........  Remove           .............     1,368.78            3       510.00  .............       102.00
                hemorrhoids &
                fistula.
46260........  Hemorrhoidectom  .............     1,368.78            3       510.00  .............       102.00
                y.
46261........  Remove           .............     1,368.78            4       630.00  .............       126.00
                hemorrhoids &
                fissure.
46262........  Remove           .............     1,368.78            4       630.00  .............       126.00
                hemorrhoids &
                fistula.
46270........  Removal of anal  .............     1,368.78            3       510.00  .............       102.00
                fistula.
46275........  Removal of anal  .............     1,368.78            3       510.00  .............       102.00
                fistula.
46280........  Removal of anal  .............     1,368.78            4       630.00  .............       126.00
                fistula.
46285........  Removal of anal  .............     1,368.78            1       333.00  .............        66.60
                fistula.
46288........  Repair anal      .............     1,368.78            4       630.00  .............       126.00
                fistula.
46608........  Anoscopy,        .............       525.41            1       333.00  .............        66.60
                remove for
                body.
46610........  Anoscopy,        .............     1,268.55            1       333.00  .............        66.60
                remove lesion.
46611........  Anoscopy.......  .............       525.41            1       333.00  .............        66.60
46612........  Anoscopy,        .............     1,268.55            1       333.00  .............        66.60
                remove lesions.
46615........  Anoscopy.......  .............     1,268.55            2       446.00  .............        89.20

[[Page 68271]]

 
46700........  Repair of anal   .............     1,368.78            3       510.00  .............       102.00
                stricture.
46706........  Repr of anal     .............     1,820.61            1       333.00  .............        66.60
                fistula w/glue.
46750........  Repair of anal   .............     2,329.58            3       510.00  .............       102.00
                sphincter.
46753........  Reconstruction   .............     1,368.78            3       510.00  .............       102.00
                of anus.
46754........  Removal of       .............     1,368.78            2       446.00  .............        89.20
                suture from
                anus.
46760........  Repair of anal   .............     2,329.58            2       446.00  .............        89.20
                sphincter.
46761........  Repair of anal   .............     2,329.58            3       510.00  .............       102.00
                sphincter.
46762........  Implant          .............     2,329.58            7       995.00  .............       199.00
                artificial
                sphincter.
46917........  Laser surgery,   .............     1,255.64            1       333.00  .............        66.60
                anal lesions.
46922........  Excision of      .............     1,255.64            1       333.00  .............        66.60
                anal lesion(s).
46924........  Destruction,     .............     1,255.64            1       333.00  .............        66.60
                anal lesion(s).
46937........  Cryotherapy of   .............     1,368.78            2       446.00  .............        89.20
                rectal lesion.
46938........  Cryotherapy of   .............     1,820.61            2       446.00  .............        89.20
                rectal lesion.
46946........  Ligation of      A*...........       783.03            1       333.00  .............        66.60
                hemorrhoids.
46947........  Hemorrhoidopexy  .............     1,820.61            7       995.00  .............       199.00
                by stapling.
47000........  Needle biopsy    .............       377.32            1       333.00  .............        66.60
                of liver.
47510........  Insert           .............     1,245.85            2       446.00  .............        89.20
                catheter, bile
                duct.
47511........  Insert bile      .............     1,245.85            9     1,245.85  Y............       249.17
                duct drain.
47525........  Change bile      .............       716.56            1       333.00  .............        66.60
                duct catheter.
47530........  Revise/reinsert  .............       716.56            1       333.00  .............        66.60
                bile tube.
47552........  Biliary          .............     1,245.85            2       446.00  .............        89.20
                endoscopy thru
                skin.
47553........  Biliary          .............     1,245.85            3       510.00  .............       102.00
                endoscopy thru
                skin.
47554........  Biliary          .............     1,245.85            3       510.00  .............       102.00
                endoscopy thru
                skin.
47555........  Biliary          .............     1,245.85            3       510.00  .............       102.00
                endoscopy thru
                skin.
47556........  Biliary          .............     1,245.85            9     1,245.85  Y............       249.17
                endoscopy thru
                skin.
47560........  Laparoscopy w/   .............     1,974.60            3       510.00  .............       102.00
                cholangio.
47561........  Laparo w/        .............     1,974.60            3       510.00  .............       102.00
                cholangio/
                biopsy.
47630........  Remove bile      .............     1,245.85            3       510.00  .............       102.00
                duct stone.
48102........  Needle biopsy,   .............       377.32            1       333.00  .............        66.60
                pancreas.
49080........  Puncture,        .............       222.78            2       222.78  Y............        44.56
                peritoneal
                cavity.
49081........  Removal of       .............       222.78            2       222.78  Y............        44.56
                abdominal
                fluid.
49085........  Remove abdomen   D............  ...........            2       446.00  .............  ...........
                foreign body.
49180........  Biopsy,          .............       377.32            1       333.00  .............        66.60
                abdominal mass.
49250........  Excision of      .............     1,357.41            4       630.00  .............       126.00
                umbilicus.
49320........  Diag laparo      .............     1,974.60            3       510.00  .............       102.00
                separate proc.
49321........  Laparoscopy,     .............     1,974.60            4       630.00  .............       126.00
                biopsy.
49322........  Laparoscopy,     .............     1,974.60            4       630.00  .............       126.00
                aspiration.
49402........  Remove foreign   A............     1,357.41            2       446.00  .............        89.20
                body, adbomen.
49419........  Insrt abdom      .............     1,795.68            1       333.00  .............        66.60
                cath for
                chemotx.
49420........  Insert abdom     .............     1,815.86            1       333.00  .............        66.60
                drain, temp.
49421........  Insert abdom     .............     1,815.86            1       333.00  .............        66.60
                drain, perm.
49422........  Remove perm      .............     1,574.45            1       333.00  .............        66.60
                cannula/
                catheter.
49426........  Revise abdomen-  .............     1,357.41            2       446.00  .............        89.20
                venous shunt.
49495........  Rpr ing hernia   .............     1,795.98            4       630.00  .............       126.00
                baby, reduc.
49496........  Rpr ing hernia   .............     1,795.98            4       630.00  .............       126.00
                baby, blocked.
49500........  Rpr ing hernia,  .............     1,795.98            4       630.00  .............       126.00
                init, reduce.
49501........  Rpr ing hernia,  .............     1,795.98            9     1,339.00  .............       267.80
                init blocked.
49505........  Prp i/hern init  .............     1,795.98            4       630.00  .............       126.00
                reduc >5 yr.
49507........  Prp i/hern init  .............     1,795.98            9     1,339.00  .............       267.80
                block >5 yr.
49520........  Rerepair ing     .............     1,795.98            7       995.00  .............       199.00
                hernia, reduce.
49521........  Rerepair ing     .............     1,795.98            9     1,339.00  .............       267.80
                hernia,
                blocked.
49525........  Repair ing       .............     1,795.98            4       630.00  .............       126.00
                hernia,
                sliding.
49540........  Repair lumbar    .............     1,795.98            2       446.00  .............        89.20
                hernia.
49550........  Rpr rem hernia,  .............     1,795.98            5       717.00  .............       143.40
                init, reduce.
49553........  Rpr fem hernia,  .............     1,795.98            9     1,339.00  .............       267.80
                init blocked.
49555........  Rerepair fem     .............     1,795.98            5       717.00  .............       143.40
                hernia, reduce.
49557........  Rerepair fem     .............     1,795.98            9     1,339.00  .............       267.80
                hernia,
                blocked.
49560........  Rpr ventral      .............     1,795.98            4       630.00  .............       126.00
                hern init,
                reduc.
49561........  Rpr ventral      .............     1,795.98            9     1,339.00  .............       267.80
                hern init,
                block.
49565........  Rerepair ventrl  .............     1,795.98            4       630.00  .............       126.00
                hern, reduce.
49566........  Rerepair ventrl  .............     1,795.98            9     1,339.00  .............       267.80
                hern, block.
49568........  Hernia repair w/ .............     1,795.98            7       995.00  .............       199.00
                mesh.
49570........  Rpr epigastric   .............     1,795.98            4       630.00  .............       126.00
                hern, reduce.
49572........  Rpr epigastric   .............     1,795.98            9     1,339.00  .............       267.80
                hern, blocked.
49580........  Rpr umbil hern,  .............     1,795.98            4       630.00  .............       126.00
                reduc < 5 yr.

[[Page 68272]]

 
49582........  Rpr umbil hern,  .............     1,795.98            9     1,339.00  .............       267.80
                block < 5 yr.
49585........  Rpr umbil hern,  .............     1,795.98            4       630.00  .............       126.00
                reduc > 5 yr.
49587........  Rpr umbil hern,  .............     1,795.98            9     1,339.00  .............       267.80
                block > 5 yr.
49590........  Repair           .............     1,795.98            3       510.00  .............       102.00
                spigelian
                hernia.
49600........  Repair           .............     1,795.98            4       630.00  .............       126.00
                umbilical
                lesion.
49650........  Laparo hernia    .............     2,676.86            4       630.00  .............       126.00
                repair initial.
49651........  Laparo hernia    .............     2,676.86            7       995.00  .............       199.00
                repair recur.
50200........  Biopsy of        .............       377.32            1       333.00  .............        66.60
                kidney.
50390........  Drainage of      .............       377.32            1       333.00  .............        66.60
                kidney lesion.
50392........  Insert kidney    .............     1,181.73            1       333.00  .............        66.60
                drain.
50393........  Insert ureteral  .............     1,181.73            1       333.00  .............        66.60
                tube.
50395........  Create passage   .............     1,181.73            1       333.00  .............        66.60
                to kidney.
50396........  Measure kidney   .............       131.50            1       131.50  Y............        26.30
                pressure.
50398........  Change kidney    .............       459.78            1       333.00  .............        66.60
                tube.
50551........  Kidney           .............       399.24            1       333.00  .............        66.60
                endoscopy.
50553........  Kidney           .............     1,181.73            1       333.00  .............        66.60
                endoscopy.
50555........  Kidney           .............       399.24            1       333.00  .............        66.60
                endoscopy &
                biopsy.
50557........  Kidney           .............     1,467.24            1       333.00  .............        66.60
                endoscopy &
                treatment.
50561........  Kidney           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                treatment.
50688........  Change of        .............       459.78            1       333.00  .............        66.60
                ureter tube/
                stent.
50947........  Laparo new       .............     2,676.86            9     1,339.00  .............       267.80
                ureter/bladder.
50948........  Laparo new       .............     2,676.86            9     1,339.00  .............       267.80
                ureter/bladder.
50951........  Endoscopy of     .............       399.24            1       333.00  .............        66.60
                ureter.
50953........  Endoscopy of     .............       399.24            1       333.00  .............        66.60
                ureter.
50955........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                biopsy.
50957........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                treatment.
50961........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                treatment.
50970........  Ureter           .............       399.24            1       333.00  .............        66.60
                endoscopy.
50972........  Ureter           .............       399.24            1       333.00  .............        66.60
                endoscopy &
                catheter.
50974........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                biopsy.
50976........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                treatment.
50980........  Ureter           .............     1,181.73            1       333.00  .............        66.60
                endoscopy &
                treatment.
51010........  Drainage of      .............     1,116.74            1       333.00  .............        66.60
                bladder.
51020........  Incise & treat   .............     1,467.24            4       630.00  .............       126.00
                bladder.
51030........  Incise & treat   .............     1,467.24            4       630.00  .............       126.00
                bladder.
51040........  Incise & drain   .............     1,467.24            4       630.00  .............       126.00
                bladder.
51045........  Incise bladder/  .............       399.24            4       399.24  Y............        79.85
                drain ureter.
51050........  Removal of       .............     1,467.24            4       630.00  .............       126.00
                bladder stone.
51065........  Remove ureter    .............     1,467.24            4       630.00  .............       126.00
                calculus.
51080........  Drainage of      .............     1,076.22            1       333.00  .............        66.60
                bladder
                abscess.
51500........  Removal of       .............     1,795.98            4       630.00  .............       126.00
                bladder cyst.
51520........  Removal of       .............     1,467.24            4       630.00  .............       126.00
                bladder lesion.
51710........  Change of        .............       459.78            1       333.00  .............        66.60
                bladder tube.
51715........  Endoscopic       .............     1,784.13            3       510.00  .............       102.00
                injection/
                implant.
51726........  Complex          .............       209.48            1       209.48  Y............        41.90
                cystometrogram.
51772........  Urethra          .............       131.50            1       131.50  Y............        26.30
                pressure
                profile.
51785........  Anal/urinary     .............        66.92            1        66.92  Y............        13.38
                muscle study.
51880........  Repair of        .............     1,467.24            1       333.00  .............        66.60
                bladder
                opening.
51992........  Laparo sling     .............     2,676.86            5       717.00  .............       143.40
                operation.
52000........  Cystoscopy.....  .............       399.24            1       333.00  .............        66.60
52001........  Cystoscopy,      .............       399.24            2       399.24  Y............        79.85
                removal of
                clots.
52005........  Cystoscopy &     .............     1,181.73            2       446.00  .............        89.20
                ureter
                catheter.
52007........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                biopsy.
52010........  Cystoscopy &     .............       399.24            2       399.24  Y............        79.85
                duct catheter.
52204........  Cystoscopy w/    .............     1,181.73            2       446.00  .............        89.20
                biopsy(s).
52214........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52224........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52234........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52235........  Cystoscopy and   .............     1,467.24            3       510.00  .............       102.00
                treatment.
52240........  Cystoscopy and   .............     1,467.24            3       510.00  .............       102.00
                treatment.
52250........  Cystoscopy and   .............     1,467.24            4       630.00  .............       126.00
                radiotracer.
52260........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52270........  Cystoscopy &     .............     1,181.73            2       446.00  .............        89.20
                revise urethra.
52275........  Cystoscopy &     .............     1,181.73            2       446.00  .............        89.20
                revise urethra.
52276........  Cystoscopy and   .............     1,181.73            3       510.00  .............       102.00
                treatment.

[[Page 68273]]

 
52277........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52281........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52282........  Cystoscopy,      .............     2,146.84            9     1,339.00  .............       267.80
                implant stent.
52283........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52285........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52290........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52300........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52301........  Cystoscopy and   .............     1,181.73            3       510.00  .............       102.00
                treatment.
52305........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52310........  Cystoscopy and   .............       399.24            2       399.24  Y............        79.85
                treatment.
52315........  Cystoscopy and   .............     1,181.73            2       446.00  .............        89.20
                treatment.
52317........  Remove bladder   .............     1,467.24            1       333.00  .............        66.60
                stone.
52318........  Remove bladder   .............     1,467.24            2       446.00  .............        89.20
                stone.
52320........  Cystoscopy and   .............     1,467.24            5       717.00  .............       143.40
                treatment.
52325........  Cystoscopy,      .............     1,467.24            4       630.00  .............       126.00
                stone removal.
52327........  Cystoscopy,      .............     1,467.24            2       446.00  .............        89.20
                inject
                material.
52330........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52332........  Cystoscopy and   .............     1,467.24            2       446.00  .............        89.20
                treatment.
52334........  Create passage   .............     1,467.24            3       510.00  .............       102.00
                to kidney.
52341........  Cysto w/ureter   .............     1,467.24            3       510.00  .............       102.00
                stricture tx.
52342........  Cysto w/up       .............     1,467.24            3       510.00  .............       102.00
                stricture tx.
52343........  Cysto w/renal    .............     1,467.24            3       510.00  .............       102.00
                stricture tx.
52344........  Cysto/uretero,   .............     1,467.24            3       510.00  .............       102.00
                stricture tx.
52345........  Cysto/uretero w/ .............     1,467.24            3       510.00  .............       102.00
                up stricture.
52346........  Cystouretero w/  .............     1,467.24            3       510.00  .............       102.00
                renal strict.
52351........  Cystouretero &   .............     1,181.73            3       510.00  .............       102.00
                or pyeloscope.
52352........  Cystouretero w/  .............     1,467.24            4       630.00  .............       126.00
                stone remove.
52353........  Cystouretero w/  .............     2,146.84            4       630.00  .............       126.00
                lithotripsy.
52354........  Cystouretero w/  .............     1,467.24            4       630.00  .............       126.00
                biopsy.
52355........  Cystouretero w/  .............     1,467.24            4       630.00  .............       126.00
                excise tumor.
52400........  Cystouretero w/  .............     1,467.24            3       510.00  .............       102.00
                congen repr.
52402........  Cystourethro     .............     1,467.24            3       510.00  .............       102.00
                cut ejacul
                duct.
52450........  Incision of      .............     1,467.24            3       510.00  .............       102.00
                prostate.
52500........  Revision of      .............     1,467.24            3       510.00  .............       102.00
                bladder neck.
52510........  Dilation         .............     1,181.73            3       510.00  .............       102.00
                prostatic
                urethra.
52601........  Prostatectomy    .............     2,146.84            4       630.00  .............       126.00
                (TURP).
52606........  Control postop   .............     1,467.24            1       333.00  .............        66.60
                bleeding.
52612........  Prostatectomy,   .............     2,146.84            2       446.00  .............        89.20
                first stage.
52614........  Prostatectomy,   .............     2,146.84            1       333.00  .............        66.60
                second stage.
52620........  Remove residual  .............     2,146.84            1       333.00  .............        66.60
                prostate.
52630........  Remove prostate  .............     2,146.84            2       446.00  .............        89.20
                regrowth.
52640........  Relieve bladder  .............     1,467.24            2       446.00  .............        89.20
                contracture.
52647........  Laser surgery    .............     2,649.30            9     1,339.00  .............       267.80
                of prostate.
52648........  Laser surgery    .............     2,649.30            9     1,339.00  .............       267.80
                of prostate.
52700........  Drainage of      .............     1,467.24            2       446.00  .............        89.20
                prostate
                abscess.
53000........  Incision of      .............     1,130.77            1       333.00  .............        66.60
                urethra.
53010........  Incision of      .............     1,130.77            1       333.00  .............        66.60
                urethra.
53020........  Incision of      .............     1,130.77            1       333.00  .............        66.60
                urethra.
53040........  Drainage of      .............     1,130.77            2       446.00  .............        89.20
                urethra
                abscess.
53080........  Drainage of      .............     1,130.77            3       510.00  .............       102.00
                urinary
                leakage.
53200........  Biopsy of        .............     1,130.77            1       333.00  .............        66.60
                urethra.
53210........  Removal of       .............     1,784.13            5       717.00  .............       143.40
                urethra.
53215........  Removal of       .............     1,130.77            5       717.00  .............       143.40
                urethra.
53220........  Treatment of     .............     1,784.13            2       446.00  .............        89.20
                urethra lesion.
53230........  Removal of       .............     1,784.13            2       446.00  .............        89.20
                urethra lesion.
53235........  Removal of       .............     1,130.77            3       510.00  .............       102.00
                urethra lesion.
53240........  Surgery for      .............     1,784.13            2       446.00  .............        89.20
                urethra pouch.
53250........  Removal of       .............     1,130.77            2       446.00  .............        89.20
                urethra gland.
53260........  Treatment of     .............     1,130.77            2       446.00  .............        89.20
                urethra lesion.
53265........  Treatment of     .............     1,130.77            2       446.00  .............        89.20
                urethra lesion.
53270........  Removal of       .............     1,130.77            2       446.00  .............        89.20
                urethra gland.
53275........  Repair of        .............     1,130.77            2       446.00  .............        89.20
                urethra defect.
53400........  Revise urethra,  .............     1,784.13            3       510.00  .............       102.00
                stage 1.
53405........  Revise urethra,  .............     1,784.13            2       446.00  .............        89.20
                stage 2.
53410........  Reconstruction   .............     1,784.13            2       446.00  .............        89.20
                of urethra.

[[Page 68274]]

 
53420........  Reconstruct      .............     1,784.13            3       510.00  .............       102.00
                urethra, stage
                1.
53425........  Reconstruct      .............     1,784.13            2       446.00  .............        89.20
                urethra, stage
                2.
53430........  Reconstruction   .............     1,784.13            2       446.00  .............        89.20
                of urethra.
53431........  Reconstruct      .............     1,784.13            2       446.00  .............        89.20
                urethra/
                bladder.
53440........  Male sling       .............     4,868.83            2       446.00  .............        89.20
                procedure.
53442........  Remove/revise    .............     1,784.13            1       333.00  .............        66.60
                male sling.
53444........  Insert tandem    .............     4,868.83            2       446.00  .............        89.20
                cuff.
53445........  Insert uro/ves   .............     8,445.07            1       333.00  .............        66.60
                nck sphincter.
53446........  Remove uro       .............     1,784.13            1       333.00  .............        66.60
                sphincter.
53447........  Remove/replace   .............     8,445.07            1       333.00  .............        66.60
                ur sphincter.
53449........  Repair uro       .............     1,784.13            1       333.00  .............        66.60
                sphincter.
53450........  Revision of      .............     1,784.13            1       333.00  .............        66.60
                urethra.
53460........  Revision of      .............     1,130.77            1       333.00  .............        66.60
                urethra.
53502........  Repair of        .............     1,130.77            2       446.00  .............        89.20
                urethra injury.
53505........  Repair of        .............     1,784.13            2       446.00  .............        89.20
                urethra injury.
53510........  Repair of        .............     1,130.77            2       446.00  .............        89.20
                urethra injury.
53515........  Repair of        .............     1,784.13            2       446.00  .............        89.20
                urethra injury.
53520........  Repair of        .............     1,784.13            2       446.00  .............        89.20
                urethra defect.
53605........  Dilate urethra   .............     1,181.73            2       446.00  .............        89.20
                stricture.
53665........  Dilation of      .............     1,130.77            1       333.00  .............        66.60
                urethra.
54000........  Slitting of      .............     1,130.77            2       446.00  .............        89.20
                prepuce.
54001........  Slitting of      .............     1,130.77            2       446.00  .............        89.20
                prepuce.
54015........  Drain penis      .............     1,076.22            4       630.00  .............       126.00
                lesion.
54057........  Laser surg,      .............     1,072.14            1       333.00  .............        66.60
                penis
                lesion(s).
54060........  Excision of      .............     1,072.14            1       333.00  .............        66.60
                penis
                lesion(s).
54065........  Destruction,     .............     1,255.64            1       333.00  .............        66.60
                penis
                lesion(s).
54100........  Biopsy of penis  .............       928.31            1       333.00  .............        66.60
54105........  Biopsy of penis  .............     1,233.39            1       333.00  .............        66.60
54110........  Treatment of     .............     2,027.66            2       446.00  .............        89.20
                penis lesion.
54111........  Treat penis      .............     2,027.66            2       446.00  .............        89.20
                lesion, graft.
54112........  Treat penis      .............     2,027.66            2       446.00  .............        89.20
                lesion, graft.
54115........  Treatment of     .............     1,076.22            1       333.00  .............        66.60
                penis lesion.
54120........  Partial removal  .............     2,027.66            2       446.00  .............        89.20
                of penis.
54150........  Circumcision w/  .............     1,263.25            1       333.00  .............        66.60
                regionl block.
54152........  Circumcision...  .............     1,263.25            1       333.00  .............        66.60
54160........  Circumcision,    .............     1,263.25            2       446.00  .............        89.20
                neonate.
54161........  Circum 28 days   .............     1,263.25            2       446.00  .............        89.20
                or older.
54162........  Lysis penil      .............     1,263.25            2       446.00  .............        89.20
                circumic
                lesion.
54163........  Repair of        .............     1,263.25            2       446.00  .............        89.20
                circumcision.
54164........  Frenulotomy of   .............     1,263.25            2       446.00  .............        89.20
                penis.
54205........  Treatment of     .............     2,027.66            4       630.00  .............       126.00
                penis lesion.
54220........  Treatment of     .............       131.50            1       131.50  Y............        26.30
                penis lesion.
54300........  Revision of      .............     2,027.66            3       510.00  .............       102.00
                penis.
54304........  Revision of      .............     2,027.66            3       510.00  .............       102.00
                penis.
54308........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54312........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54316........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54318........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54322........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54324........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54326........  Reconstruction   .............     2,027.66            3       510.00  .............       102.00
                of urethra.
54328........  Revise penis/    .............     2,027.66            3       510.00  .............       102.00
                urethra.
54340........  Secondary        .............     2,027.66            3       510.00  .............       102.00
                urethral
                surgery.
54344........  Secondary        .............     2,027.66            3       510.00  .............       102.00
                urethral
                surgery.
54348........  Secondary        .............     2,027.66            3       510.00  .............       102.00
                urethral
                surgery.
54352........  Reconstruct      .............     2,027.66            3       510.00  .............       102.00
                urethra/penis.
54360........  Penis plastic    .............     2,027.66            3       510.00  .............       102.00
                surgery.
54380........  Repair penis...  .............     2,027.66            3       510.00  .............       102.00
54385........  Repair penis...  .............     2,027.66            3       510.00  .............       102.00
54400........  Insert semi-     .............     4,868.83            3       510.00  .............       102.00
                rigid
                prosthesis.
54401........  Insert self-     .............     8,445.07            3       510.00  .............       102.00
                contd
                prosthesis.
54405........  Insert multi-    .............     8,445.07            3       510.00  .............       102.00
                comp penis
                pros.
54406........  Remove muti-     .............     2,027.66            3       510.00  .............       102.00
                comp penis
                pros.
54408........  Repair multi-    .............     2,027.66            3       510.00  .............       102.00
                comp penis
                pros.
54410........  Remove/replace   .............     8,445.07            3       510.00  .............       102.00
                penis prosth.

[[Page 68275]]

 
54415........  Remove self-     .............     2,027.66            3       510.00  .............       102.00
                contd penis
                pros.
54416........  Remv/repl penis  .............     8,445.07            3       510.00  .............       102.00
                contain pros.
54420........  Revision of      .............     2,027.66            4       630.00  .............       126.00
                penis.
54435........  Revision of      .............     2,027.66            4       630.00  .............       126.00
                penis.
54440........  Repair of penis  .............     2,027.66            4       630.00  .............       126.00
54450........  Preputial        .............       209.48            1       209.48  Y............        41.90
                stretching.
54500........  Biopsy of        .............       631.00            1       333.00  .............        66.60
                testis.
54505........  Biopsy of        .............     1,446.40            1       333.00  .............        66.60
                testis.
54512........  Excise lesion    .............     1,446.40            2       446.00  .............        89.20
                testis.
54520........  Removal of       .............     1,446.40            3       510.00  .............       102.00
                testis.
54522........  Orchiectomy,     .............     1,446.40            3       510.00  .............       102.00
                partial.
54530........  Removal of       .............     1,795.98            4       630.00  .............       126.00
                testis.
54550........  Exploration for  .............     1,795.98            4       630.00  .............       126.00
                testis.
54600........  Reduce testis    .............     1,446.40            4       630.00  .............       126.00
                torsion.
54620........  Suspension of    .............     1,446.40            3       510.00  .............       102.00
                testis.
54640........  Suspension of    .............     1,795.98            4       630.00  .............       126.00
                testis.
54660........  Revision of      .............     1,446.40            2       446.00  .............        89.20
                testis.
54670........  Repair testis    .............     1,446.40            3       510.00  .............       102.00
                injury.
54680........  Relocation of    .............     1,446.40            3       510.00  .............       102.00
                testis(es).
54690........  Laparoscopy,     .............     2,676.86            9     1,339.00  .............       267.80
                orchiectomy.
54700........  Drainage of      .............     1,446.40            2       446.00  .............        89.20
                scrotum.
54800........  Biopsy of        .............       127.16            1       127.16  Y............        25.43
                epididymis.
54820........  Exploration of   D............  ...........            1       333.00  .............  ...........
                epididymis.
54830........  Remove           .............     1,446.40            3       510.00  .............       102.00
                epididymis
                lesion.
54840........  Remove           .............     1,446.40            4       630.00  .............       126.00
                epididymis
                lesion.
54860........  Removal of       .............     1,446.40            3       510.00  .............       102.00
                epididymis.
54861........  Removal of       .............     1,446.40            4       630.00  .............       126.00
                epididymis.
54865........  Explore          A............     1,446.40            1       333.00  .............        66.60
                epididymis.
54900........  Fusion of        .............     1,446.40            4       630.00  .............       126.00
                spermatic
                ducts.
54901........  Fusion of        .............     1,446.40            4       630.00  .............       126.00
                spermatic
                ducts.
55040........  Removal of       .............     1,795.98            3       510.00  .............       102.00
                hydrocele.
55041........  Removal of       .............     1,795.98            5       717.00  .............       143.40
                hydroceles.
55060........  Repair of        .............     1,446.40            4       630.00  .............       126.00
                hydrocele.
55100........  Drainage of      .............       685.58            1       333.00  .............        66.60
                scrotum
                abscess.
55110........  Explore scrotum  .............     1,446.40            2       446.00  .............        89.20
55120........  Removal of       .............     1,446.40            2       446.00  .............        89.20
                scrotum lesion.
55150........  Removal of       .............     1,446.40            1       333.00  .............        66.60
                scrotum.
55175........  Revision of      .............     1,446.40            1       333.00  .............        66.60
                scrotum.
55180........  Revision of      .............     1,446.40            2       446.00  .............        89.20
                scrotum.
55200........  Incision of      .............     1,446.40            2       446.00  .............        89.20
                sperm duct.
55250........  Removal of       .............     1,446.40            2       446.00  .............        89.20
                sperm duct(s).
55400........  Repair of sperm  .............     1,446.40            1       333.00  .............        66.60
                duct.
55500........  Removal of       .............     1,446.40            3       510.00  .............       102.00
                hydrocele.
55520........  Removal of       .............     1,446.40            4       630.00  .............       126.00
                sperm cord
                lesion.
55530........  Revise           .............     1,446.40            4       630.00  .............       126.00
                spermatic cord
                veins.
55535........  Revise           .............     1,795.98            4       630.00  .............       126.00
                spermatic cord
                veins.
55540........  Revise hernia &  .............     1,795.98            5       717.00  .............       143.40
                sperm veins.
55550........  Laparo ligate    .............     2,676.86            9     1,339.00  .............       267.80
                spermatic vein.
55680........  Remove sperm     .............     1,446.40            1       333.00  .............        66.60
                pouch lesion.
55700........  Biopsy of        .............       345.83            2       345.83  Y............        69.17
                prostate.
55705........  Biopsy of        .............       345.83            2       345.83  Y............        69.17
                prostate.
55720........  Drainage of      .............     1,467.24            1       333.00  .............        66.60
                prostate
                abscess.
55725........  Drainage of      .............     1,467.24            2       446.00  .............        89.20
                prostate
                abscess.
55859........  Percut/needle    D............  ...........            9     1,339.00  .............  ...........
                insert, pros.
55873........  Cryoablate       .............     6,685.05            9     1,339.00  .............       267.80
                prostate.
55875........  Transperi        A............     2,146.84            9     1,339.00  .............       267.80
                needle place,
                pros.
56440........  Surgery for      .............     1,260.59            2       446.00  .............        89.20
                vulva lesion.
56441........  Lysis of labial  .............       912.73            1       333.00  .............        66.60
                lesion(s).
56442........  Hymenotomy.....  A............       912.73            1       333.00  .............        66.60
56515........  Destroy vulva    .............     1,255.64            3       510.00  .............       102.00
                lesion/s compl.
56620........  Partial removal  .............     1,752.42            5       717.00  .............       143.40
                of vulva.
56625........  Complete         .............     1,752.42            7       995.00  .............       199.00
                removal of
                vulva.
56700........  Partial removal  .............     1,260.59            1       333.00  .............        66.60
                of hymen.
56720........  Incision of      D............  ...........            1       333.00  .............  ...........
                hymen.
56740........  Remove vagina    .............     1,260.59            3       510.00  .............       102.00
                gland lesion.

[[Page 68276]]

 
56800........  Repair of        .............     1,260.59            3       510.00  .............       102.00
                vagina.
56810........  Repair of        .............     1,260.59            5       717.00  .............       143.40
                perineum.
57000........  Exploration of   .............       912.73            1       333.00  .............        66.60
                vagina.
57010........  Drainage of      .............       912.73            2       446.00  .............        89.20
                pelvic abscess.
57020........  Drainage of      .............       409.33            2       409.33  Y............        81.87
                pelvic fluid.
57023........  I & d vag        .............     1,076.22            1       333.00  .............        66.60
                hematoma, non-
                ob.
57065........  Destroy vag      .............     1,260.59            1       333.00  .............        66.60
                lesions,
                complex.
57105........  Biopsy of        .............     1,260.59            2       446.00  .............        89.20
                vagina.
57130........  Remove vagina    .............     1,260.59            2       446.00  .............        89.20
                lesion.
57135........  Remove vagina    .............     1,260.59            2       446.00  .............        89.20
                lesion.
57155........  Insert uteri     .............       409.33            2       409.33  Y............        81.87
                tandems/ovoids.
57180........  Treat vaginal    .............       178.05            1       178.05  Y............        35.61
                bleeding.
57200........  Repair of        .............     1,260.59            1       333.00  .............        66.60
                vagina.
57210........  Repair vagina/   .............     1,260.59            2       446.00  .............        89.20
                perineum.
57220........  Revision of      .............     2,642.48            3       510.00  .............       102.00
                urethra.
57230........  Repair of        .............     1,752.42            3       510.00  .............       102.00
                urethral
                lesion.
57240........  Repair bladder   .............     1,752.42            5       717.00  .............       143.40
                & vagina.
57250........  Repair rectum &  .............     1,752.42            5       717.00  .............       143.40
                vagina.
57260........  Repair of        .............     1,752.42            5       717.00  .............       143.40
                vagina.
57265........  Extensive        .............     2,642.48            7       995.00  .............       199.00
                repair of
                vagina.
57267........  Insert mesh/     A*...........     1,752.42            7       995.00  .............       199.00
                pelvic flr
                addon.
57268........  Repair of bowel  .............     1,752.42            3       510.00  .............       102.00
                bulge.
57288........  Repair bladder   .............     2,642.48            5       717.00  .............       143.40
                defect.
57289........  Repair bladder   .............     1,752.42            5       717.00  .............       143.40
                & vagina.
57291........  Construction of  .............     1,752.42            5       717.00  .............       143.40
                vagina.
57300........  Repair rectum-   .............     1,752.42            3       510.00  .............       102.00
                vagina fistula.
57400........  Dilation of      .............     1,260.59            2       446.00  .............        89.20
                vagina.
57410........  Pelvic           .............       912.73            2       446.00  .............        89.20
                examination.
57415........  Remove vaginal   .............     1,260.59            2       446.00  .............        89.20
                foreign body.
57513........  Laser surgery    .............       912.73            2       446.00  .............        89.20
                of cervix.
57520........  Conization of    .............     1,260.59            2       446.00  .............        89.20
                cervix.
57522........  Conization of    .............     1,752.42            2       446.00  .............        89.20
                cervix.
57530........  Removal of       .............     1,752.42            3       510.00  .............       102.00
                cervix.
57550........  Removal of       .............     1,752.42            3       510.00  .............       102.00
                residual
                cervix.
57556........  Remove cervix,   .............     2,642.48            5       717.00  .............       143.40
                repair bowel.
57558........  D&c of cervical  A............     1,091.05            3       510.00  .............       102.00
                stump.
57700........  Revision of      .............     1,260.59            1       333.00  .............        66.60
                cervix.
57720........  Revision of      .............     1,260.59            3       510.00  .............       102.00
                cervix.
57820........  D & c of         D............  ...........            3       510.00  .............  ...........
                residual
                cervix.
58120........  Dilation and     .............     1,091.05            2       446.00  .............        89.20
                curettage.
58145........  Myomectomy vag   .............     1,752.42            5       717.00  .............       143.40
                method.
58346........  Insert heyman    .............       912.73            2       446.00  .............        89.20
                uteri capsule.
58350........  Reopen           .............     1,752.42            3       510.00  .............       102.00
                fallopian tube.
58353........  Endometr         .............     1,752.42            7       995.00  .............       199.00
                ablate,
                thermal.
58545........  Laparoscopic     .............     1,974.60            9     1,339.00  .............       267.80
                myomectomy.
58546........  Laparo-          .............     2,676.86            9     1,339.00  .............       267.80
                myomectomy,
                complex.
58550........  Laparo-asst vag  .............     4,333.90            9     1,339.00  .............       267.80
                hysterectomy.
58555........  Hysteroscopy,    .............     1,312.87            1       333.00  .............        66.60
                dx, sep proc.
58558........  Hysteroscopy,    .............     1,312.87            3       510.00  .............       102.00
                biopsy.
58559........  Hysteroscopy,    .............     1,312.87            2       446.00  .............        89.20
                lysis.
58560........  Hysteroscopy,    .............     2,090.86            3       510.00  .............       102.00
                resect septum.
58561........  Hysteroscopy,    .............     2,090.86            3       510.00  .............       102.00
                remove myoma.
58562........  Hysteroscopy,    .............     1,312.87            3       510.00  .............       102.00
                remove fb.
58563........  Hysteroscopy,    .............     2,090.86            9     1,339.00  .............       267.80
                ablation.
58565........  Hysteroscopy,    .............     2,642.48            9     1,339.00  .............       267.80
                sterilization.
58660........  Laparoscopy,     .............     2,676.86            5       717.00  .............       143.40
                lysis.
58661........  Laparoscopy,     .............     2,676.86            5       717.00  .............       143.40
                remove adnexa.
58662........  Laparoscopy,     .............     2,676.86            5       717.00  .............       143.40
                excise lesions.
58670........  Laparoscopy,     .............     2,676.86            3       510.00  .............       102.00
                tubal cautery.
58671........  Laparoscopy,     .............     2,676.86            3       510.00  .............       102.00
                tubal block.
58672........  Laparoscopy,     .............     2,676.86            5       717.00  .............       143.40
                fimbrioplasty.
58673........  Laparoscopy,     .............     2,676.86            5       717.00  .............       143.40
                salpingostomy.
58800........  Drainage of      .............       912.73            3       510.00  .............       102.00
                ovarian
                cyst(s).
58820........  Drain ovary      .............     1,752.42            3       510.00  .............       102.00
                abscess, open.
58900........  Biopsy of        .............       912.73            3       510.00  .............       102.00
                ovary(s).

[[Page 68277]]

 
58970........  Retrieval of     .............       245.92            1       245.92  Y............        49.18
                oocyte.
58974........  Transfer of      .............       245.92            1       245.92  Y............        49.18
                embryo.
58976........  Transfer of      .............       245.92            1       245.92  Y............        49.18
                embryo.
59160........  D& c after       .............     1,091.05            3       510.00  .............       102.00
                delivery.
59320........  Revision of      .............     1,260.59            1       333.00  .............        66.60
                cervix.
59812........  Treatment of     .............     1,138.39            5       717.00  .............       143.40
                miscarriage.
59820........  Care of          .............     1,138.39            5       717.00  .............       143.40
                miscarriage.
59821........  Treatment of     .............     1,138.39            5       717.00  .............       143.40
                miscarriage.
59840........  Abortion.......  .............     1,040.83            5       717.00  .............       143.40
59841........  Abortion.......  .............     1,040.83            5       717.00  .............       143.40
59870........  Evacuate mole    .............     1,138.39            5       717.00  .............       143.40
                of uterus.
59871........  Remove cerclage  .............     1,260.59            5       717.00  .............       143.40
                suture.
60000........  Drain thyroid/   .............       464.15            1       333.00  .............        66.60
                tongue cyst.
60200........  Remove thyroid   .............     2,318.72            2       446.00  .............        89.20
                lesion.
60280........  Remove thyroid   .............     2,318.72            4       630.00  .............       126.00
                duct lesion.
60281........  Remove thyroid   .............     2,318.72            4       630.00  .............       126.00
                duct lesion.
61020........  Remove brain     .............       183.83            1       183.83  Y............        36.77
                cavity fluid.
61026........  Injection into   .............       183.83            1       183.83  Y............        36.77
                brain canal.
61050........  Remove brain     .............       183.83            1       183.83  Y............        36.77
                canal fluid.
61055........  Injection into   .............       183.83            1       183.83  Y............        36.77
                brain canal.
61070........  Brain canal      .............       183.83            1       183.83  Y............        36.77
                shunt
                procedure.
61215........  Insert brain-    .............     2,891.10            3       510.00  .............       102.00
                fluid device.
61790........  Treat            .............     1,097.20            3       510.00  .............       102.00
                trigeminal
                nerve.
61791........  Treat            .............       351.92            3       351.92  Y............        70.38
                trigeminal
                tract.
61795........  Brain surgery    A*...........       302.04            1       302.04  Y............        60.41
                using computer.
61885........  Insrt/redo       .............    11,518.00            2       446.00  .............        89.20
                neurostim 1
                array.
61886........  Implant          .............    14,932.81            3       510.00  .............       102.00
                neurostim
                arrays.
61888........  Revise/remove    .............     2,186.43            1       333.00  .............        66.60
                neuroreceiver.
62194........  Replace/         .............       716.56            1       333.00  .............        66.60
                irrigate
                catheter.
62225........  Replace/         .............       716.56            1       333.00  .............        66.60
                irrigate
                catheter.
62230........  Replace/revise   .............     2,891.10            2       446.00  .............        89.20
                brain shunt.
62263........  Epidural lysis   .............       748.08            1       333.00  .............        66.60
                mult sessions.
62264........  Epidural lysis   .............       748.08            1       333.00  .............        66.60
                on single day.
62268........  Drain spinal     .............       183.83            1       183.83  Y............        36.77
                cord cyst.
62269........  Needle biopsy,   .............       377.32            1       333.00  .............        66.60
                spinal cord.
62270........  Spinal fluid     .............       139.00            1       139.00  Y............        27.80
                tap,
                diagnostic.
62272........  Drain cerebro    .............       139.00            1       139.00  Y............        27.80
                spinal fluid.
62273........  Inject epidural  .............       351.92            1       333.00  .............        66.60
                patch.
62280........  Treat spinal     .............       390.95            1       333.00  .............        66.60
                cord lesion.
62281........  Treat spinal     .............       390.95            1       333.00  .............        66.60
                cord lesion.
62282........  Treat spinal     .............       390.95            1       333.00  .............        66.60
                canal lesion.
62287........  Percutaneous     .............     2,037.79            9     1,339.00  .............       267.80
                diskectomy.
62294........  Injection into   .............       183.83            3       183.83  Y............        36.77
                spinal artery.
62310........  Inject spine c/  .............       390.95            1       333.00  .............        66.60
                t.
62311........  Inject spine l/  .............       390.95            1       333.00  .............        66.60
                s (cd).
62318........  Inject spine w/  .............       390.95            1       333.00  .............        66.60
                cath, c/t.
62319........  Inject spine w/  .............       390.95            1       333.00  .............        66.60
                cath l/s (cd).
62350........  Implant spinal   .............     1,895.64            2       446.00  .............        89.20
                canal cath.
62355........  Remove spinal    .............       748.08            2       446.00  .............        89.20
                canal catheter.
62360........  Insert spine     .............     6,923.28            2       446.00  .............        89.20
                infusion
                device.
62361........  Implant spine    .............    10,720.36            2       446.00  .............        89.20
                infusion pump.
62362........  Implant spine    .............    10,720.36            2       446.00  .............        89.20
                infusion pump.
62365........  Remove spine     .............     2,037.79            2       446.00  .............        89.20
                infusion
                device.
63600........  Remove spinal    .............     1,097.20            2       446.00  .............        89.20
                cord lesion.
63610........  Stimulation of   .............     1,097.20            1       333.00  .............        66.60
                spinal cord.
63650........  Implant          .............     3,477.28            2       446.00  .............        89.20
                neuroelectrode
                s.
63660........  Revise/remove    .............     1,096.18            1       333.00  .............        66.60
                neuroelectrode.
63685........  Insrt/redo       .............    11,164.12            2       446.00  .............        89.20
                spine n
                generator.
63688........  Revise/remove    .............     2,186.43            1       333.00  .............        66.60
                neuroreceiver.
63744........  Revision of      .............     2,413.44            3       510.00  .............       102.00
                spinal shunt.
63746........  Removal of       .............       675.64            2       446.00  .............        89.20
                spinal shunt.
64410........  Nblock inj,      .............       351.92            1       333.00  .............        66.60
                phrenic.
64415........  Nblock inj,      .............       139.00            1       139.00  Y............        27.80
                brachial
                plexus.
64417........  Nblock inj,      .............       139.00            1       139.00  Y............        27.80
                axillary.
64420........  Nblock inj,      .............       139.00            1       139.00  Y............        27.80
                intercost, sng.

[[Page 68278]]

 
64421........  Nblock inj,      .............       351.92            1       333.00  .............        66.60
                intercost, mlt.
64430........  Nblock inj,      .............       139.00            1       139.00  Y............        27.80
                pudendal.
64470........  Inj              .............       390.95            1       333.00  .............        66.60
                paravertebral
                c/t.
64472........  Inj              .............       351.92            1       333.00  .............        66.60
                paravertebral
                c/t add-on.
64475........  Inj              .............       390.95            1       333.00  .............        66.60
                paravertebral
                l/s.
64476........  Inj              .............       351.92            1       333.00  .............        66.60
                paravertebral
                l/s add-on.
64479........  Inj foramen      .............       390.95            1       333.00  .............        66.60
                epidural c/t.
64480........  Inj foramen      .............       390.95            1       333.00  .............        66.60
                epidural add-
                on.
64483........  Inj foramen      .............       390.95            1       333.00  .............        66.60
                epidural l/s.
64484........  Inj foramen      .............       390.95            1       333.00  .............        66.60
                epidural add-
                on.
64510........  Nblock,          .............       390.95            1       333.00  .............        66.60
                stellate
                ganglion.
64517........  Nblock inj,      .............       139.00            2       139.00  Y............        27.80
                hypogas plxs.
64520........  Nblock, lumbar/  .............       390.95            1       333.00  .............        66.60
                thoracic.
64530........  Nblock inj,      .............       390.95            1       333.00  .............        66.60
                celiac pelus.
64553........  Implant          .............    13,593.72            1       333.00  .............        66.60
                neuroelectrode
                s.
64561........  Implant          .............     3,477.28            3       510.00  .............       102.00
                neuroelectrode
                s.
64573........  Implant          .............    13,593.72            1       333.00  .............        66.60
                neuroelectrode
                s.
64575........  Implant          .............     5,175.40            1       333.00  .............        66.60
                neuroelectrode
                s.
64577........  Implant          .............     5,175.40            1       333.00  .............        66.60
                neuroelectrode
                s.
64580........  Implant          .............     5,175.40            1       333.00  .............        66.60
                neuroelectrode
                s.
64581........  Implant          .............     5,175.40            3       510.00  .............       102.00
                neuroelectrode
                s.
64585........  Revise/remove    .............     1,096.18            1       333.00  .............        66.60
                neuroelectrode.
64590........  Insrt/redo pn/   .............    11,164.12            2       446.00  .............        89.20
                gastr stimul.
64595........  Revise/rmv pn/   .............     2,186.43            1       333.00  .............        66.60
                gastr stimul.
64600........  Injection        .............       748.08            1       333.00  .............        66.60
                treatment of
                nerve.
64605........  Injection        .............       748.08            1       333.00  .............        66.60
                treatment of
                nerve.
64610........  Injection        .............       748.08            1       333.00  .............        66.60
                treatment of
                nerve.
64620........  Injection        .............       748.08            1       333.00  .............        66.60
                treatment of
                nerve.
64622........  Destr            .............       748.08            1       333.00  .............        66.60
                paravertebrl
                nerve l/s.
64623........  Destr            .............       390.95            1       333.00  .............        66.60
                paravertebral
                n add-on.
64626........  Destr            .............       748.08            1       333.00  .............        66.60
                paravertebrl
                nerve c/t.
64627........  Destr            .............       390.95            1       333.00  .............        66.60
                paravertebral
                n add-on.
64630........  Injection        .............       351.92            2       351.92  Y............        70.38
                treatment of
                nerve.
64680........  Injection        .............       390.95            2       390.95  Y............        78.19
                treatment of
                nerve.
64681........  Injection        .............       748.08            2       446.00  .............        89.20
                treatment of
                nerve.
64702........  Revise finger/   .............     1,097.20            1       333.00  .............        66.60
                toe nerve.
64704........  Revise hand/     .............     1,097.20            1       333.00  .............        66.60
                foot nerve.
64708........  Revise arm/leg   .............     1,097.20            2       446.00  .............        89.20
                nerve.
64712........  Revision of      .............     1,097.20            2       446.00  .............        89.20
                sciatic nerve.
64713........  Revision of arm  .............     1,097.20            2       446.00  .............        89.20
                nerve(s).
64714........  Revise low back  .............     1,097.20            2       446.00  .............        89.20
                nerve(s).
64716........  Revision of      .............     1,097.20            3       510.00  .............       102.00
                cranial nerve.
64718........  Revise ulnar     .............     1,097.20            2       446.00  .............        89.20
                nerve at elbow.
64719........  Revise ulnar     .............     1,097.20            2       446.00  .............        89.20
                nerve at wrist.
64721........  Carpal tunnel    .............     1,097.20            2       446.00  .............        89.20
                surgery.
64722........  Relieve          .............     1,097.20            1       333.00  .............        66.60
                pressure on
                nerve(s).
64726........  Release foot/    .............     1,097.20            1       333.00  .............        66.60
                toe nerve.
64727........  Internal nerve   .............     1,097.20            1       333.00  .............        66.60
                revision.
64732........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                brow nerve.
64734........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                cheek nerve.
64736........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                chin nerve.
64738........  Incision of jaw  .............     1,097.20            2       446.00  .............        89.20
                nerve.
64740........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                tongue nerve.
64742........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                facial nerve.
64744........  Incise nerve,    .............     1,097.20            2       446.00  .............        89.20
                back of head.
64746........  Incise           .............     1,097.20            2       446.00  .............        89.20
                diaphragm
                nerve.
64771........  Sever cranial    .............     1,097.20            2       446.00  .............        89.20
                nerve.
64772........  Incision of      .............     1,097.20            2       446.00  .............        89.20
                spinal nerve.
64774........  Remove skin      .............     1,097.20            2       446.00  .............        89.20
                nerve lesion.
64776........  Remove digit     .............     1,097.20            3       510.00  .............       102.00
                nerve lesion.
64778........  Digit nerve      .............     1,097.20            2       446.00  .............        89.20
                surgery add-on.
64782........  Remove limb      .............     1,097.20            3       510.00  .............       102.00
                nerve lesion.
64783........  Limb nerve       .............     1,097.20            2       446.00  .............        89.20
                surgery add-on.
64784........  Remove nerve     .............     1,097.20            3       510.00  .............       102.00
                lesion.
64786........  Remove sciatic   .............     2,037.79            3       510.00  .............       102.00
                nerve lesion.

[[Page 68279]]

 
64787........  Implant nerve    .............     1,097.20            2       446.00  .............        89.20
                end.
64788........  Remove skin      .............     1,097.20            3       510.00  .............       102.00
                nerve lesion.
64790........  Removal of       .............     1,097.20            3       510.00  .............       102.00
                nerve lesion.
64792........  Removal of       .............     2,037.79            3       510.00  .............       102.00
                nerve lesion.
64795........  Biopsy of nerve  .............     1,097.20            2       446.00  .............        89.20
64802........  Remove           .............     1,097.20            2       446.00  .............        89.20
                sympathetic
                nerves.
64821........  Remove           .............     1,590.53            4       630.00  .............       126.00
                sympathetic
                nerves.
64831........  Repair of digit  .............     2,037.79            4       630.00  .............       126.00
                nerve.
64832........  Repair nerve     .............     2,037.79            1       333.00  .............        66.60
                add-on.
64834........  Repair of hand   .............     2,037.79            2       446.00  .............        89.20
                or foot nerve.
64835........  Repair of hand   .............     2,037.79            3       510.00  .............       102.00
                or foot nerve.
64836........  Repair of hand   .............     2,037.79            3       510.00  .............       102.00
                or foot nerve.
64837........  Repair nerve     .............     2,037.79            1       333.00  .............        66.60
                add-on.
64840........  Repair of leg    .............     2,037.79            2       446.00  .............        89.20
                nerve.
64856........  Repair/          .............     2,037.79            2       446.00  .............        89.20
                transpose
                nerve.
64857........  Repair arm/leg   .............     2,037.79            2       446.00  .............        89.20
                nerve.
64858........  Repair sciatic   .............     2,037.79            2       446.00  .............        89.20
                nerve.
64859........  Nerve surgery..  .............     2,037.79            1       333.00  .............        66.60
64861........  Repair of arm    .............     2,037.79            3       510.00  .............       102.00
                nerves.
64862........  Repair of low    .............     2,037.79            3       510.00  .............       102.00
                back nerves.
64864........  Repair of        .............     2,037.79            3       510.00  .............       102.00
                facial nerve.
64865........  Repair of        .............     2,037.79            4       630.00  .............       126.00
                facial nerve.
64870........  Fusion of        .............     2,037.79            4       630.00  .............       126.00
                facial/other
                nerve.
64872........  Subsequent       .............     2,037.79            2       446.00  .............        89.20
                repair of
                nerve.
64874........  Repair & revise  .............     2,037.79            3       510.00  .............       102.00
                nerve add-on.
64876........  Repair nerve/    .............     2,037.79            3       510.00  .............       102.00
                shorten bone.
64885........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                head or neck.
64886........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                head or neck.
64890........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                hand or foot.
64891........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                hand or foot.
64892........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                arm or leg.
64893........  Nerve graft,     .............     2,037.79            2       446.00  .............        89.20
                arm or leg.
64895........  Nerve graft,     .............     2,037.79            3       510.00  .............       102.00
                hand or foot.
64896........  Nerve graft,     .............     2,037.79            3       510.00  .............       102.00
                hand or foot.
64897........  Nerve graft,     .............     2,037.79            3       510.00  .............       102.00
                arm or leg.
64898........  Nerve graft,     .............     2,037.79            3       510.00  .............       102.00
                arm or leg.
64901........  Nerve graft add- .............     2,037.79            2       446.00  .............        89.20
                on.
64902........  Nerve graft add- .............     2,037.79            2       446.00  .............        89.20
                on.
64905........  Nerve pedicle    .............     2,037.79            2       446.00  .............        89.20
                transfer.
64907........  Nerve pedicle    .............     2,037.79            1       333.00  .............        66.60
                transfer.
65091........  Revise eye.....  .............     2,165.47            3       510.00  .............       102.00
65093........  Revise eye with  .............     2,165.47            3       510.00  .............       102.00
                implant.
65101........  Removal of eye.  .............     2,165.47            3       510.00  .............       102.00
65103........  Remove eye/      .............     2,165.47            3       510.00  .............       102.00
                insert implant.
65105........  Remove eye/      .............     2,165.47            4       630.00  .............       126.00
                attach implant.
65110........  Removal of eye.  .............     2,165.47            5       717.00  .............       143.40
65112........  Remove eye/      .............     2,165.47            7       995.00  .............       199.00
                revise socket.
65114........  Remove eye/      .............     2,165.47            7       995.00  .............       199.00
                revise socket.
65130........  Insert ocular    .............     1,552.37            3       510.00  .............       102.00
                implant.
65135........  Insert ocular    .............     1,552.37            2       446.00  .............        89.20
                implant.
65140........  Attach ocular    .............     2,165.47            3       510.00  .............       102.00
                implant.
65150........  Revise ocular    .............     1,552.37            2       446.00  .............        89.20
                implant.
65155........  Reinsert ocular  .............     2,165.47            3       510.00  .............       102.00
                implant.
65175........  Removal of       .............     1,052.60            1       333.00  .............        66.60
                ocular implant.
65235........  Remove foreign   .............       935.91            2       446.00  .............        89.20
                body from eye.
65260........  Remove foreign   .............     1,015.69            3       510.00  .............       102.00
                body from eye.
65265........  Remove foreign   .............     1,696.64            4       630.00  .............       126.00
                body from eye.
65270........  Repair of eye    .............     1,052.60            2       446.00  .............        89.20
                wound.
65272........  Repair of eye    .............     1,413.58            2       446.00  .............        89.20
                wound.
65275........  Repair of eye    .............     1,413.58            4       630.00  .............       126.00
                wound.
65280........  Repair of eye    .............     1,015.69            4       630.00  .............       126.00
                wound.
65285........  Repair of eye    .............     2,300.69            4       630.00  .............       126.00
                wound.
65290........  Repair of eye    .............     1,308.05            3       510.00  .............       102.00
                socket wound.
65400........  Removal of eye   .............       935.91            1       333.00  .............        66.60
                lesion.
65410........  Biopsy of        .............       935.91            2       446.00  .............        89.20
                cornea.

[[Page 68280]]

 
65420........  Removal of eye   .............       935.91            2       446.00  .............        89.20
                lesion.
65426........  Removal of eye   .............     1,413.58            5       717.00  .............       143.40
                lesion.
65710........  Corneal          .............     2,352.42            7       995.00  .............       199.00
                transplant.
65730........  Corneal          .............     2,352.42            7       995.00  .............       199.00
                transplant.
65750........  Corneal          .............     2,352.42            7       995.00  .............       199.00
                transplant.
65755........  Corneal          .............     2,352.42            7       995.00  .............       199.00
                transplant.
65770........  Revise cornea    .............     3,195.68            7       995.00  .............       199.00
                with implant.
65772........  Correction of    .............       935.91            4       630.00  .............       126.00
                astigmatism.
65775........  Correction of    .............       935.91            4       630.00  .............       126.00
                astigmatism.
65780........  Ocular reconst,  .............     2,352.42            5       717.00  .............       143.40
                transplant.
65781........  Ocular reconst,  .............     2,352.42            5       717.00  .............       143.40
                transplant.
65782........  Ocular reconst,  .............     2,352.42            5       717.00  .............       143.40
                transplant.
65800........  Drainage of eye  .............       935.91            1       333.00  .............        66.60
65805........  Drainage of eye  .............       935.91            1       333.00  .............        66.60
65810........  Drainage of eye  .............     1,413.58            3       510.00  .............       102.00
65815........  Drainage of eye  .............     1,413.58            2       446.00  .............        89.20
65820........  Relieve inner    .............       372.94            1       333.00  .............        66.60
                eye pressure.
65850........  Incision of eye  .............     1,413.58            4       630.00  .............       126.00
65865........  Incise inner     .............       935.91            1       333.00  .............        66.60
                eye adhesions.
65870........  Incise inner     .............     1,413.58            4       630.00  .............       126.00
                eye adhesions.
65875........  Incise inner     .............     1,413.58            4       630.00  .............       126.00
                eye adhesions.
65880........  Incise inner     .............       935.91            4       630.00  .............       126.00
                eye adhesions.
65900........  Remove eye       .............       935.91            5       717.00  .............       143.40
                lesion.
65920........  Remove implant   .............     1,413.58            7       995.00  .............       199.00
                of eye.
65930........  Remove blood     .............     1,413.58            5       717.00  .............       143.40
                clot from eye.
66020........  Injection        .............       935.91            1       333.00  .............        66.60
                treatment of
                eye.
66030........  Injection        .............       372.94            1       333.00  .............        66.60
                treatment of
                eye.
66130........  Remove eye       .............     1,413.58            7       995.00  .............       199.00
                lesion.
66150........  Glaucoma         .............     1,413.58            4       630.00  .............       126.00
                surgery.
66155........  Glaucoma         .............     1,413.58            4       630.00  .............       126.00
                surgery.
66160........  Glaucoma         .............     1,413.58            2       446.00  .............        89.20
                surgery.
66165........  Glaucoma         .............     1,413.58            4       630.00  .............       126.00
                surgery.
66170........  Glaucoma         .............     1,413.58            4       630.00  .............       126.00
                surgery.
66172........  Incision of eye  .............     1,413.58            4       630.00  .............       126.00
66180........  Implant eye      .............     2,329.43            5       717.00  .............       143.40
                shunt.
66185........  Revise eye       .............     2,329.43            2       446.00  .............        89.20
                shunt.
66220........  Repair eye       .............     2,300.69            3       510.00  .............       102.00
                lesion.
66225........  Repair/graft     .............     2,329.43            4       630.00  .............       126.00
                eye lesion.
66250........  Follow-up        .............       935.91            2       446.00  .............        89.20
                surgery of eye.
66500........  Incision of      .............       372.94            1       333.00  .............        66.60
                iris.
66505........  Incision of      .............       372.94            1       333.00  .............        66.60
                iris.
66600........  Remove iris and  .............     1,413.58            3       510.00  .............       102.00
                lesion.
66605........  Removal of iris  .............     1,413.58            3       510.00  .............       102.00
66625........  Removal of iris  .............       372.94            3       372.94  Y............        74.59
66630........  Removal of iris  .............     1,413.58            3       510.00  .............       102.00
66635........  Removal of iris  .............     1,413.58            3       510.00  .............       102.00
66680........  Repair iris &    .............     1,413.58            3       510.00  .............       102.00
                ciliary body.
66682........  Repair iris &    .............     1,413.58            2       446.00  .............        89.20
                ciliary body.
66700........  Destruction,     .............       935.91            2       446.00  .............        89.20
                ciliary body.
66710........  Ciliary          .............       935.91            2       446.00  .............        89.20
                transsleral
                therapy.
66711........  Ciliary          .............       935.91            2       446.00  .............        89.20
                endoscopic
                ablation.
66720........  Destruction,     .............       935.91            2       446.00  .............        89.20
                ciliary body.
66740........  Destruction,     .............     1,413.58            2       446.00  .............        89.20
                ciliary body.
66821........  After cataract   .............       312.50            2       312.50  Y............        62.50
                laser surgery.
66825........  Reposition       .............     1,413.58            4       630.00  .............       126.00
                intraocular
                lens.
66830........  Removal of lens  .............       372.94            4       372.94  Y............        74.59
                lesion.
66840........  Removal of lens  .............       914.04            4       630.00  .............       126.00
                material.
66850........  Removal of lens  .............     1,796.59            7       995.00  .............       199.00
                material.
66852........  Removal of lens  .............     1,796.59            4       630.00  .............       126.00
                material.
66920........  Extraction of    .............     1,796.59            4       630.00  .............       126.00
                lens.
66930........  Extraction of    .............     1,796.59            5       717.00  .............       143.40
                lens.
66940........  Extraction of    .............       914.04            5       717.00  .............       143.40
                lens.
66982........  Cataract         .............     1,452.57            8       973.00  .............       194.60
                surgery,
                complex.
66983........  Cataract surg w/ .............     1,452.57            8       973.00  .............       194.60
                iol, 1 stage.
66984........  Cataract surg w/ .............     1,452.57            8       973.00  .............       194.60
                iol, 1 stage.

[[Page 68281]]

 
66985........  Insert lens      .............     1,452.57            6       826.00  .............       165.20
                prosthesis.
66986........  Exchange lens    .............     1,452.57            6       826.00  .............       165.20
                prosthesis.
67005........  Partial removal  .............     1,696.64            4       630.00  .............       126.00
                of eye fluid.
67010........  Partial removal  .............     1,696.64            4       630.00  .............       126.00
                of eye fluid.
67015........  Release of eye   .............     1,696.64            1       333.00  .............        66.60
                fluid.
67025........  Replace eye      .............     1,696.64            1       333.00  .............        66.60
                fluid.
67027........  Implant eye      .............     2,300.69            4       630.00  .............       126.00
                drug system.
67030........  Incise inner     .............     1,015.69            1       333.00  .............        66.60
                eye strands.
67031........  Laser surgery,   .............       312.50            2       312.50  Y............        62.50
                eye strands.
67036........  Removal of       .............     2,300.69            4       630.00  .............       126.00
                inner eye
                fluid.
67038........  Strip retinal    .............     2,300.69            5       717.00  .............       143.40
                membrane.
67039........  Laser treatment  .............     2,300.69            7       995.00  .............       199.00
                of retina.
67040........  Laser treatment  .............     2,300.69            7       995.00  .............       199.00
                of retina.
67107........  Repair detached  .............     2,300.69            5       717.00  .............       143.40
                retina.
67108........  Repair detached  .............     2,300.69            7       995.00  .............       199.00
                retina.
67112........  Rerepair         .............     2,300.69            7       995.00  .............       199.00
                detached
                retina.
67115........  Release          .............     1,015.69            2       446.00  .............        89.20
                encircling
                material.
67120........  Remove eye       .............     1,015.69            2       446.00  .............        89.20
                implant
                material.
67121........  Remove eye       .............     1,696.64            2       446.00  .............        89.20
                implant
                material.
67141........  Treatment of     .............       241.77            2       241.77  Y............        48.35
                retina.
67218........  Treatment of     .............     1,015.69            5       717.00  .............       143.40
                retinal lesion.
67227........  Treatment of     .............     1,696.64            1       333.00  .............        66.60
                retinal lesion.
67250........  Reinforce eye    .............     1,052.60            3       510.00  .............       102.00
                wall.
67255........  Reinforce/graft  .............     1,696.64            3       510.00  .............       102.00
                eye wall.
67311........  Revise eye       .............     1,308.05            3       510.00  .............       102.00
                muscle.
67312........  Revise two eye   .............     1,308.05            4       630.00  .............       126.00
                muscles.
67314........  Revise eye       .............     1,308.05            4       630.00  .............       126.00
                muscle.
67316........  Revise two eye   .............     1,308.05            4       630.00  .............       126.00
                muscles.
67318........  Revise eye       .............     1,308.05            4       630.00  .............       126.00
                muscle(s).
67320........  Revise eye       .............     1,308.05            4       630.00  .............       126.00
                muscle(s) add-
                on.
67331........  Eye surgery      .............     1,308.05            4       630.00  .............       126.00
                follow-up add-
                on.
67332........  Rerevise eye     .............     1,308.05            4       630.00  .............       126.00
                muscles add-on.
67334........  Revise eye       .............     1,308.05            4       630.00  .............       126.00
                muscle w/
                suture.
67335........  Eye suture       .............     1,308.05            4       630.00  .............       126.00
                during surgery.
67340........  Revise eye       .............     1,308.05            4       630.00  .............       126.00
                muscle add-on.
67343........  Release eye      .............     1,308.05            7       995.00  .............       199.00
                tissue.
67346........  Biopsy, eye      A............       884.19            1       333.00  .............        66.60
                muscle.
67350........  Biopsy eye       D............  ...........            1       333.00  .............  ...........
                muscle.
67400........  Explore/biopsy   .............     1,552.37            3       510.00  .............       102.00
                eye socket.
67405........  Explore/drain    .............     1,552.37            4       630.00  .............       126.00
                eye socket.
67412........  Explore/treat    .............     1,552.37            5       717.00  .............       143.40
                eye socket.
67413........  Explore/treat    .............     1,552.37            5       717.00  .............       143.40
                eye socket.
67415........  Aspiration,      .............     1,052.60            1       333.00  .............        66.60
                orbital
                contents.
67420........  Explore/treat    .............     2,165.47            5       717.00  .............       143.40
                eye socket.
67430........  Explore/treat    .............     2,165.47            5       717.00  .............       143.40
                eye socket.
67440........  Explore/drain    .............     2,165.47            5       717.00  .............       143.40
                eye socket.
67445........  Explr/           .............     2,165.47            5       717.00  .............       143.40
                decompress eye
                socket.
67450........  Explore/biopsy   .............     2,165.47            5       717.00  .............       143.40
                eye socket.
67550........  Insert eye       .............     2,165.47            4       630.00  .............       126.00
                socket implant.
67560........  Revise eye       .............     1,552.37            2       446.00  .............        89.20
                socket implant.
67570........  Decompress       .............     2,165.47            4       630.00  .............       126.00
                optic nerve.
67715........  Incision of      .............     1,052.60            1       333.00  .............        66.60
                eyelid fold.
67808........  Remove eyelid    .............     1,052.60            2       446.00  .............        89.20
                lesion(s).
67830........  Revise           .............       447.60            2       446.00  .............        89.20
                eyelashes.
67835........  Revise           .............     1,052.60            2       446.00  .............        89.20
                eyelashes.
67880........  Revision of      .............       935.91            3       510.00  .............       102.00
                eyelid.
67882........  Revision of      .............     1,052.60            3       510.00  .............       102.00
                eyelid.
67900........  Repair brow      .............     1,052.60            4       630.00  .............       126.00
                defect.
67901........  Repair eyelid    .............     1,052.60            5       717.00  .............       143.40
                defect.
67902........  Repair eyelid    .............     1,052.60            5       717.00  .............       143.40
                defect.
67903........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67904........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67906........  Repair eyelid    .............     1,052.60            5       717.00  .............       143.40
                defect.
67908........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67909........  Revise eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.

[[Page 68282]]

 
67911........  Revise eyelid    .............     1,052.60            3       510.00  .............       102.00
                defect.
67912........  Correction       .............     1,052.60            3       510.00  .............       102.00
                eyelid w/
                implant.
67914........  Repair eyelid    .............     1,052.60            3       510.00  .............       102.00
                defect.
67916........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67917........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67921........  Repair eyelid    .............     1,052.60            3       510.00  .............       102.00
                defect.
67923........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67924........  Repair eyelid    .............     1,052.60            4       630.00  .............       126.00
                defect.
67935........  Repair eyelid    .............     1,052.60            2       446.00  .............        89.20
                wound.
67950........  Revision of      .............     1,052.60            2       446.00  .............        89.20
                eyelid.
67961........  Revision of      .............     1,052.60            3       510.00  .............       102.00
                eyelid.
67966........  Revision of      .............     1,052.60            3       510.00  .............       102.00
                eyelid.
67971........  Reconstruction   .............     1,552.37            3       510.00  .............       102.00
                of eyelid.
67973........  Reconstruction   .............     1,552.37            3       510.00  .............       102.00
                of eyelid.
67974........  Reconstruction   .............     1,552.37            3       510.00  .............       102.00
                of eyelid.
67975........  Reconstruction   .............     1,052.60            3       510.00  .............       102.00
                of eyelid.
68115........  Remove eyelid    .............     1,052.60            2       446.00  .............        89.20
                lining lesion.
68130........  Remove eyelid    .............       935.91            2       446.00  .............        89.20
                lining lesion.
68320........  Revise/graft     .............     1,052.60            4       630.00  .............       126.00
                eyelid lining.
68325........  Revise/graft     .............     1,552.37            4       630.00  .............       126.00
                eyelid lining.
68326........  Revise/graft     .............     1,552.37            4       630.00  .............       126.00
                eyelid lining.
68328........  Revise/graft     .............     1,552.37            4       630.00  .............       126.00
                eyelid lining.
68330........  Revise eyelid    .............     1,413.58            4       630.00  .............       126.00
                lining.
68335........  Revise/graft     .............     1,552.37            4       630.00  .............       126.00
                eyelid lining.
68340........  Separate eyelid  .............     1,052.60            4       630.00  .............       126.00
                adhesions.
68360........  Revise eyelid    .............     1,413.58            2       446.00  .............        89.20
                lining.
68362........  Revise eyelid    .............     1,413.58            2       446.00  .............        89.20
                lining.
68371........  Harvest eye      .............       935.91            2       446.00  .............        89.20
                tissue,
                alograft.
68500........  Removal of tear  .............     1,552.37            3       510.00  .............       102.00
                gland.
68505........  Partial          .............     1,552.37            3       510.00  .............       102.00
                removal, tear
                gland.
68510........  Biopsy of tear   .............     1,052.60            1       333.00  .............        66.60
                gland.
68520........  Removal of tear  .............     1,552.37            3       510.00  .............       102.00
                sac.
68525........  Biopsy of tear   .............     1,052.60            1       333.00  .............        66.60
                sac.
68540........  Remove tear      .............     1,552.37            3       510.00  .............       102.00
                gland lesion.
68550........  Remove tear      .............     1,552.37            3       510.00  .............       102.00
                gland lesion.
68700........  Repair tear      .............     1,552.37            2       446.00  .............        89.20
                ducts.
68720........  Create tear sac  .............     1,552.37            4       630.00  .............       126.00
                drain.
68745........  Create tear      .............     1,552.37            4       630.00  .............       126.00
                duct drain.
68750........  Create tear      .............     1,552.37            4       630.00  .............       126.00
                duct drain.
68770........  Close tear       .............     1,052.60            4       630.00  .............       126.00
                system fistula.
68810........  Probe            .............       131.86            1       131.86  Y............        26.37
                nasolacrimal
                duct.
68811........  Probe            .............     1,052.60            2       446.00  .............        89.20
                nasolacrimal
                duct.
68815........  Probe            .............     1,052.60            2       446.00  .............        89.20
                nasolacrimal
                duct.
69110........  Remove external  .............       928.31            1       333.00  .............        66.60
                ear, partial.
69120........  Removal of       .............     1,434.04            2       446.00  .............        89.20
                external ear.
69140........  Remove ear       .............     1,434.04            2       446.00  .............        89.20
                canal
                lesion(s).
69145........  Remove ear       .............       928.31            2       446.00  .............        89.20
                canal
                lesion(s).
69150........  Extensive ear    .............       464.15            3       464.15  Y............        92.83
                canal surgery.
69205........  Clear outer ear  .............     1,233.39            1       333.00  .............        66.60
                canal.
69300........  Revise external  .............     1,434.04            3       510.00  .............       102.00
                ear.
69310........  Rebuild outer    .............     2,348.02            3       510.00  .............       102.00
                ear canal.
69320........  Rebuild outer    .............     2,348.02            7       995.00  .............       199.00
                ear canal.
69421........  Incision of      .............     1,009.71            3       510.00  .............       102.00
                eardrum.
69436........  Create eardrum   .............     1,009.71            3       510.00  .............       102.00
                opening.
69440........  Exploration of   .............     1,434.04            3       510.00  .............       102.00
                middle ear.
69450........  Eardrum          .............     2,348.02            1       333.00  .............        66.60
                revision.
69501........  Mastoidectomy..  .............     2,348.02            7       995.00  .............       199.00
69502........  Mastoidectomy..  .............     1,434.04            7       995.00  .............       199.00
69505........  Remove mastoid   .............     2,348.02            7       995.00  .............       199.00
                structures.
69511........  Extensive        .............     2,348.02            7       995.00  .............       199.00
                mastoid
                surgery.
69530........  Extensive        .............     2,348.02            7       995.00  .............       199.00
                mastoid
                surgery.
69550........  Remove ear       .............     2,348.02            5       717.00  .............       143.40
                lesion.
69552........  Remove ear       .............     2,348.02            7       995.00  .............       199.00
                lesion.
69601........  Mastoid surgery  .............     2,348.02            7       995.00  .............       199.00
                revision.
69602........  Mastoid surgery  .............     2,348.02            7       995.00  .............       199.00
                revision.

[[Page 68283]]

 
69603........  Mastoid surgery  .............     2,348.02            7       995.00  .............       199.00
                revision.
69604........  Mastoid surgery  .............     2,348.02            7       995.00  .............       199.00
                revision.
69605........  Mastoid surgery  .............     2,348.02            7       995.00  .............       199.00
                revision.
69620........  Repair of        .............     1,434.04            2       446.00  .............        89.20
                eardrum.
69631........  Repair eardrum   .............     2,348.02            5       717.00  .............       143.40
                structures.
69632........  Rebuild eardrum  .............     2,348.02            5       717.00  .............       143.40
                structures.
69633........  Rebuild eardrum  .............     2,348.02            5       717.00  .............       143.40
                structures.
69635........  Repair eardrum   .............     2,348.02            7       995.00  .............       199.00
                structures.
69636........  Rebuild eardrum  .............     2,348.02            7       995.00  .............       199.00
                structures.
69637........  Rebuild eardrum  .............     2,348.02            7       995.00  .............       199.00
                structures.
69641........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69642........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69643........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69644........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69645........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69646........  Revise middle    .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69650........  Release middle   .............     1,434.04            7       995.00  .............       199.00
                ear bone.
69660........  Revise middle    .............     2,348.02            5       717.00  .............       143.40
                ear bone.
69661........  Revise middle    .............     2,348.02            5       717.00  .............       143.40
                ear bone.
69662........  Revise middle    .............     2,348.02            5       717.00  .............       143.40
                ear bone.
69666........  Repair middle    .............     2,348.02            4       630.00  .............       126.00
                ear structures.
69667........  Repair middle    .............     2,348.02            4       630.00  .............       126.00
                ear structures.
69670........  Remove mastoid   .............     2,348.02            3       510.00  .............       102.00
                air cells.
69676........  Remove middle    .............     2,348.02            3       510.00  .............       102.00
                ear nerve.
69700........  Close mastoid    .............     2,348.02            3       510.00  .............       102.00
                fistula.
69711........  Remove/repair    .............     2,348.02            1       333.00  .............        66.60
                hearing aid.
69714........  Implant temple   .............     2,348.02            9     1,339.00  .............       267.80
                bone w/stimul.
69715........  Temple bne       .............     2,348.02            9     1,339.00  .............       267.80
                implnt w/
                stimulat.
69717........  Temple bone      .............     2,348.02            9     1,339.00  .............       267.80
                implant
                revision.
69718........  Revise temple    .............     2,348.02            9     1,339.00  .............       267.80
                bone implant.
69720........  Release facial   .............     2,348.02            5       717.00  .............       143.40
                nerve.
69740........  Repair facial    .............     2,348.02            5       717.00  .............       143.40
                nerve.
69745........  Repair facial    .............     2,348.02            5       717.00  .............       143.40
                nerve.
69801........  Incise inner     .............     2,348.02            5       717.00  .............       143.40
                ear.
69802........  Incise inner     .............     2,348.02            7       995.00  .............       199.00
                ear.
69805........  Explore inner    .............     2,348.02            7       995.00  .............       199.00
                ear.
69806........  Explore inner    .............     2,348.02            7       995.00  .............       199.00
                ear.
69820........  Establish inner  .............     2,348.02            5       717.00  .............       143.40
                ear window.
69840........  Revise inner     .............     2,348.02            5       717.00  .............       143.40
                ear window.
69905........  Remove inner     .............     2,348.02            7       995.00  .............       199.00
                ear.
69910........  Remove inner     .............     2,348.02            7       995.00  .............       199.00
                ear & mastoid.
69915........  Incise inner     .............     2,348.02            7       995.00  .............       199.00
                ear nerve.
69930........  Implant          .............    25,499.72            7       995.00  .............       199.00
                cochlear
                device.
0176T........  Aqu canal dilat  A............     2,329.43            9     1,339.00  .............       267.80
                w/o retent.
0177T........  Aqu canal dilat  A............     2,329.43            9     1,339.00  .............       267.80
                w retent.
G0105........  Colorectal       .............       446.00            2       446.00  .............       111.50
                scrn; hi risk
                ind.
G0121........  Colon ca scrn    .............       446.00            2       446.00  .............       111.50
                not hi rsk ind.
G0260........  Inj for          .............       351.92            1       333.00  .............        66.60
                sacroiliac jt
                anesth.
G0392........  AV fistula or    A............     2,624.19            9     1,339.00  .............       334.75
                graft arterial.
G0393........  AV fistula or    A............     2,624.19            9     1,339.00  .............       334.75
                graft venous.
----------------------------------------------------------------------------------------------------------------


              Addendum B.--Payment Status by HCPCS Code and Related Information Calendar Year 2007
----------------------------------------------------------------------------------------------------------------
                                                                                           National     Minimum
  CPT/ HCPCS         Description        CI      SI        APC      Relative     Payment   unadjusted  unadjusted
                                                                    weight       rate      copayment   copayment
----------------------------------------------------------------------------------------------------------------
00100.........  Anesth, salivary      ......  N       ..........  ..........  ..........  ..........  ..........
                 gland.
00102.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 cleft lip.
00103.........  Anesth,               ......  N       ..........  ..........  ..........  ..........  ..........
                 blepharoplasty.
00104.........  Anesth, electroshock  ......  N       ..........  ..........  ..........  ..........  ..........
00120.........  Anesth, ear surgery.  ......  N       ..........  ..........  ..........  ..........  ..........
00124.........  Anesth, ear exam....  ......  N       ..........  ..........  ..........  ..........  ..........
00126.........  Anesth, tympanotomy.  ......  N       ..........  ..........  ..........  ..........  ..........

[[Page 68284]]

 
00140.........  Anesth, procedures    ......  N       ..........  ..........  ..........  ..........  ..........
                 on eye.
00142.........  Anesth, lens surgery  ......  N       ..........  ..........  ..........  ..........  ..........
00144.........  Anesth, corneal       ......  N       ..........  ..........  ..........  ..........  ..........
                 transplant.
00145.........  Anesth,               ......  N       ..........  ..........  ..........  ..........  ..........
                 vitreoretinal surg.
00147.........  Anesth, iridectomy..  ......  N       ..........  ..........  ..........  ..........  ..........
00148.........  Anesth, eye exam....  ......  N       ..........  ..........  ..........  ..........  ..........
00160.........  Anesth, nose/sinus    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00162.........  Anesth, nose/sinus    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00164.........  Anesth, biopsy of     ......  N       ..........  ..........  ..........  ..........  ..........
                 nose.
00170.........  Anesth, procedure on  ......  N       ..........  ..........  ..........  ..........  ..........
                 mouth.
00172.........  Anesth, cleft palate  ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
00174.........  Anesth, pharyngeal    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00190.........  Anesth, face/skull    ......  N       ..........  ..........  ..........  ..........  ..........
                 bone surg.
00210.........  Anesth, open head     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00212.........  Anesth, skull         ......  N       ..........  ..........  ..........  ..........  ..........
                 drainage.
00216.........  Anesth, head vessel   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00218.........  Anesth, special head  ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00220.........  Anesth, intrcrn       ......  N       ..........  ..........  ..........  ..........  ..........
                 nerve.
00222.........  Anesth, head nerve    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00300.........  Anesth, head/neck/    ......  N       ..........  ..........  ..........  ..........  ..........
                 ptrunk.
00320.........  Anesth, neck organ,   ......  N       ..........  ..........  ..........  ..........  ..........
                 1 & over.
00322.........  Anesth, biopsy of     ......  N       ..........  ..........  ..........  ..........  ..........
                 thyroid.
00326.........  Anesth, larynx/       ......  N       ..........  ..........  ..........  ..........  ..........
                 trach, < 1 yr.
00350.........  Anesth, neck vessel   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00352.........  Anesth, neck vessel   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00400.........  Anesth, skin, ext/    ......  N       ..........  ..........  ..........  ..........  ..........
                 per/atrunk.
00402.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 breast.
00404.........  Anesth, surgery of    CH....  N       ..........  ..........  ..........  ..........  ..........
                 breast.
00406.........  Anesth, surgery of    CH....  N       ..........  ..........  ..........  ..........  ..........
                 breast.
00410.........  Anesth, correct       ......  N       ..........  ..........  ..........  ..........  ..........
                 heart rhythm.
00450.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 shoulder.
00454.........  Anesth, collar bone   ......  N       ..........  ..........  ..........  ..........  ..........
                 biopsy.
00470.........  Anesth, removal of    ......  N       ..........  ..........  ..........  ..........  ..........
                 rib.
00472.........  Anesth, chest wall    ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
00500.........  Anesth, esophageal    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00520.........  Anesth, chest         ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
00522.........  Anesth, chest lining  ......  N       ..........  ..........  ..........  ..........  ..........
                 biopsy.
00528.........  Anesth, chest         ......  N       ..........  ..........  ..........  ..........  ..........
                 partition view.
00529.........  Anesth, chest         ......  N       ..........  ..........  ..........  ..........  ..........
                 partition view.
00530.........  Anesth, pacemaker     ......  N       ..........  ..........  ..........  ..........  ..........
                 insertion.
00532.........  Anesth, vascular      ......  N       ..........  ..........  ..........  ..........  ..........
                 access.
00534.........  Anesth, cardioverter/ ......  N       ..........  ..........  ..........  ..........  ..........
                 defib.
00537.........  Anesth, cardiac       ......  N       ..........  ..........  ..........  ..........  ..........
                 electrophys.
00539.........  Anesth, trach-bronch  ......  N       ..........  ..........  ..........  ..........  ..........
                 reconst.
00541.........  Anesth, one lung      ......  N       ..........  ..........  ..........  ..........  ..........
                 ventilation.
00548.........  Anesth,               ......  N       ..........  ..........  ..........  ..........  ..........
                 trachea,bronchi
                 surg.
00550.........  Anesth, sternal       ......  N       ..........  ..........  ..........  ..........  ..........
                 debridement.
00563.........  Anesth, heart surg w/ ......  N       ..........  ..........  ..........  ..........  ..........
                 arrest.
00566.........  Anesth, cabg w/o      ......  N       ..........  ..........  ..........  ..........  ..........
                 pump.
00600.........  Anesth, spine, cord   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00620.........  Anesth, spine, cord   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00625.........  Anes spine tranthor   NI....  N       ..........  ..........  ..........  ..........  ..........
                 w/o vent.
00626.........  Anes, spine           NI....  N       ..........  ..........  ..........  ..........  ..........
                 transthor w/vent.
00630.........  Anesth, spine, cord   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00634.........  Anesth for            ......  N       ..........  ..........  ..........  ..........  ..........
                 chemonucleolysis.
00635.........  Anesth, lumbar        ......  N       ..........  ..........  ..........  ..........  ..........
                 puncture.
00640.........  Anesth, spine         ......  N       ..........  ..........  ..........  ..........  ..........
                 manipulation.
00700.........  Anesth, abdominal     ......  N       ..........  ..........  ..........  ..........  ..........
                 wall surg.
00702.........  Anesth, for liver     ......  N       ..........  ..........  ..........  ..........  ..........
                 biopsy.
00730.........  Anesth, abdominal     ......  N       ..........  ..........  ..........  ..........  ..........
                 wall surg.
00740.........  Anesth, upper gi      ......  N       ..........  ..........  ..........  ..........  ..........
                 visualize.
00750.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00752.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00754.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00756.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00770.........  Anesth, blood vessel  ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
00790.........  Anesth, surg upper    ......  N       ..........  ..........  ..........  ..........  ..........
                 abdomen.
00797.........  Anesth, surgery for   ......  N       ..........  ..........  ..........  ..........  ..........
                 obesity.
00800.........  Anesth, abdominal     ......  N       ..........  ..........  ..........  ..........  ..........
                 wall surg.
00810.........  Anesth, low           ......  N       ..........  ..........  ..........  ..........  ..........
                 intestine scope.

[[Page 68285]]

 
00820.........  Anesth, abdominal     ......  N       ..........  ..........  ..........  ..........  ..........
                 wall surg.
00830.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00832.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 hernia.
00834.........  Anesth, hernia        ......  N       ..........  ..........  ..........  ..........  ..........
                 repair< 1 yr.
00836.........  Anesth hernia repair  ......  N       ..........  ..........  ..........  ..........  ..........
                 preemie.
00840.........  Anesth, surg lower    ......  N       ..........  ..........  ..........  ..........  ..........
                 abdomen.
00842.........  Anesth,               ......  N       ..........  ..........  ..........  ..........  ..........
                 amniocentesis.
00851.........  Anesth, tubal         ......  N       ..........  ..........  ..........  ..........  ..........
                 ligation.
00860.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 abdomen.
00862.........  Anesth, kidney/       ......  N       ..........  ..........  ..........  ..........  ..........
                 ureter surg.
00870.........  Anesth, bladder       ......  N       ..........  ..........  ..........  ..........  ..........
                 stone surg.
00872.........  Anesth kidney stone   ......  N       ..........  ..........  ..........  ..........  ..........
                 destruct.
00873.........  Anesth kidney stone   ......  N       ..........  ..........  ..........  ..........  ..........
                 destruct.
00880.........  Anesth, abdomen       ......  N       ..........  ..........  ..........  ..........  ..........
                 vessel surg.
00902.........  Anesth, anorectal     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00906.........  Anesth, removal of    ......  N       ..........  ..........  ..........  ..........  ..........
                 vulva.
00910.........  Anesth, bladder       ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00912.........  Anesth, bladder       ......  N       ..........  ..........  ..........  ..........  ..........
                 tumor surg.
00914.........  Anesth, removal of    ......  N       ..........  ..........  ..........  ..........  ..........
                 prostate.
00916.........  Anesth, bleeding      ......  N       ..........  ..........  ..........  ..........  ..........
                 control.
00918.........  Anesth, stone         ......  N       ..........  ..........  ..........  ..........  ..........
                 removal.
00920.........  Anesth, genitalia     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00921.........  Anesth, vasectomy...  ......  N       ..........  ..........  ..........  ..........  ..........
00922.........  Anesth, sperm duct    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
00924.........  Anesth, testis        ......  N       ..........  ..........  ..........  ..........  ..........
                 exploration.
00926.........  Anesth, removal of    ......  N       ..........  ..........  ..........  ..........  ..........
                 testis.
00928.........  Anesth, removal of    ......  N       ..........  ..........  ..........  ..........  ..........
                 testis.
00930.........  Anesth, testis        ......  N       ..........  ..........  ..........  ..........  ..........
                 suspension.
00938.........  Anesth, insert penis  ......  N       ..........  ..........  ..........  ..........  ..........
                 device.
00940.........  Anesth, vaginal       ......  N       ..........  ..........  ..........  ..........  ..........
                 procedures.
00942.........  Anesth, surg on vag/  ......  N       ..........  ..........  ..........  ..........  ..........
                 urethral.
00948.........  Anesth, repair of     ......  N       ..........  ..........  ..........  ..........  ..........
                 cervix.
00950.........  Anesth, vaginal       ......  N       ..........  ..........  ..........  ..........  ..........
                 endoscopy.
00952.........  Anesth, hysteroscope/ ......  N       ..........  ..........  ..........  ..........  ..........
                 graph.
01112.........  Anesth, bone          ......  N       ..........  ..........  ..........  ..........  ..........
                 aspirate/bx.
01120.........  Anesth, pelvis        ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01130.........  Anesth, body cast     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01160.........  Anesth, pelvis        ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01170.........  Anesth, pelvis        ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01173.........  Anesth, fx repair,    ......  N       ..........  ..........  ..........  ..........  ..........
                 pelvis.
01180.........  Anesth, pelvis nerve  ......  N       ..........  ..........  ..........  ..........  ..........
                 removal.
01190.........  Anesth, pelvis nerve  ......  N       ..........  ..........  ..........  ..........  ..........
                 removal.
01200.........  Anesth, hip joint     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01202.........  Anesth, arthroscopy   ......  N       ..........  ..........  ..........  ..........  ..........
                 of hip.
01210.........  Anesth, hip joint     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01215.........  Anesth, revise hip    ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
01220.........  Anesth, procedure on  ......  N       ..........  ..........  ..........  ..........  ..........
                 femur.
01230.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 femur.
01250.........  Anesth, upper leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01260.........  Anesth, upper leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 veins surg.
01270.........  Anesth, thigh         ......  N       ..........  ..........  ..........  ..........  ..........
                 arteries surg.
01320.........  Anesth, knee area     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01340.........  Anesth, knee area     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01360.........  Anesth, knee area     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01380.........  Anesth, knee joint    ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01382.........  Anesth, dx knee       ......  N       ..........  ..........  ..........  ..........  ..........
                 arthroscopy.
01390.........  Anesth, knee area     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01392.........  Anesth, knee area     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01400.........  Anesth, knee joint    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01420.........  Anesth, knee joint    ......  N       ..........  ..........  ..........  ..........  ..........
                 casting.
01430.........  Anesth, knee veins    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01432.........  Anesth, knee vessel   ......  N       ..........  ..........  ..........  ..........  ..........
                 surg.
01440.........  Anesth, knee          ......  N       ..........  ..........  ..........  ..........  ..........
                 arteries surg.
01462.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01464.........  Anesth, ankle/ft      ......  N       ..........  ..........  ..........  ..........  ..........
                 arthroscopy.
01470.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01472.........  Anesth, achilles      ......  N       ..........  ..........  ..........  ..........  ..........
                 tendon surg.
01474.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01480.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 bone surg.
01482.........  Anesth, radical leg   ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.

[[Page 68286]]

 
01484.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 revision.
01490.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 casting.
01500.........  Anesth, leg arteries  ......  N       ..........  ..........  ..........  ..........  ..........
                 surg.
01520.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein surg.
01522.........  Anesth, lower leg     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein surg.
01610.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 shoulder.
01620.........  Anesth, shoulder      ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01622.........  Anes dx shoulder      ......  N       ..........  ..........  ..........  ..........  ..........
                 arthroscopy.
01630.........  Anesth, surgery of    ......  N       ..........  ..........  ..........  ..........  ..........
                 shoulder.
01650.........  Anesth, shoulder      ......  N       ..........  ..........  ..........  ..........  ..........
                 artery surg.
01670.........  Anesth, shoulder      ......  N       ..........  ..........  ..........  ..........  ..........
                 vein surg.
01680.........  Anesth, shoulder      ......  N       ..........  ..........  ..........  ..........  ..........
                 casting.
01682.........  Anesth, airplane      ......  N       ..........  ..........  ..........  ..........  ..........
                 cast.
01710.........  Anesth, elbow area    ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01712.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 tendon surg.
01714.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 tendon surg.
01716.........  Anesth, biceps        ......  N       ..........  ..........  ..........  ..........  ..........
                 tendon repair.
01730.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01732.........  Anesth, dx elbow      ......  N       ..........  ..........  ..........  ..........  ..........
                 arthroscopy.
01740.........  Anesth, upper arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01742.........  Anesth, humerus       ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01744.........  Anesth, humerus       ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
01758.........  Anesth, humeral       ......  N       ..........  ..........  ..........  ..........  ..........
                 lesion surg.
01760.........  Anesth, elbow         ......  N       ..........  ..........  ..........  ..........  ..........
                 replacement.
01770.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 artery surg.
01772.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 embolectomy.
01780.........  Anesth, upper arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein surg.
01782.........  Anesth, uppr arm      ......  N       ..........  ..........  ..........  ..........  ..........
                 vein repair.
01810.........  Anesth, lower arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01820.........  Anesth, lower arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01829.........  Anesth, dx wrist      ......  N       ..........  ..........  ..........  ..........  ..........
                 arthroscopy.
01830.........  Anesth, lower arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 surgery.
01832.........  Anesth, wrist         ......  N       ..........  ..........  ..........  ..........  ..........
                 replacement.
01840.........  Anesth, lwr arm       ......  N       ..........  ..........  ..........  ..........  ..........
                 artery surg.
01842.........  Anesth, lwr arm       ......  N       ..........  ..........  ..........  ..........  ..........
                 embolectomy.
01844.........  Anesth, vascular      ......  N       ..........  ..........  ..........  ..........  ..........
                 shunt surg.
01850.........  Anesth, lower arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein surg.
01852.........  Anesth, lwr arm vein  ......  N       ..........  ..........  ..........  ..........  ..........
                 repair.
01860.........  Anesth, lower arm     ......  N       ..........  ..........  ..........  ..........  ..........
                 casting.
01905.........  Anes, spine inject,   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray/re.
01916.........  Anesth, dx            ......  N       ..........  ..........  ..........  ..........  ..........
                 arteriography.
01920.........  Anesth, catheterize   ......  N       ..........  ..........  ..........  ..........  ..........
                 heart.
01922.........  Anesth, cat or MRI    ......  N       ..........  ..........  ..........  ..........  ..........
                 scan.
01924.........  Anes, ther interven   ......  N       ..........  ..........  ..........  ..........  ..........
                 rad, art.
01925.........  Anes, ther interven   ......  N       ..........  ..........  ..........  ..........  ..........
                 rad, car.
01926.........  Anes, tx interv rad   ......  N       ..........  ..........  ..........  ..........  ..........
                 hrt/cran.
01930.........  Anes, ther interven   ......  N       ..........  ..........  ..........  ..........  ..........
                 rad, vei.
01931.........  Anes, ther interven   ......  N       ..........  ..........  ..........  ..........  ..........
                 rad, tip.
01932.........  Anes, tx interv rad,  ......  N       ..........  ..........  ..........  ..........  ..........
                 th vein.
01933.........  Anes, tx interv rad,  ......  N       ..........  ..........  ..........  ..........  ..........
                 cran v.
01951.........  Anesth, burn, less 4  ......  N       ..........  ..........  ..........  ..........  ..........
                 percent.
01952.........  Anesth, burn, 4-9     ......  N       ..........  ..........  ..........  ..........  ..........
                 percent.
01953.........  Anesth, burn, each 9  ......  N       ..........  ..........  ..........  ..........  ..........
                 percent.
01958.........  Anesth, antepartum    ......  N       ..........  ..........  ..........  ..........  ..........
                 manipul.
01960.........  Anesth, vaginal       ......  N       ..........  ..........  ..........  ..........  ..........
                 delivery.
01961.........  Anesth, cs delivery.  ......  N       ..........  ..........  ..........  ..........  ..........
01962.........  Anesth, emer          ......  N       ..........  ..........  ..........  ..........  ..........
                 hysterectomy.
01963.........  Anesth, cs            ......  N       ..........  ..........  ..........  ..........  ..........
                 hysterectomy.
01965.........  Anesth, inc/missed    ......  N       ..........  ..........  ..........  ..........  ..........
                 ab proc.
01966.........  Anesth, induced ab    ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
01967.........  Anesth/analg, vag     ......  N       ..........  ..........  ..........  ..........  ..........
                 delivery.
01968.........  Anes/analg cs         ......  N       ..........  ..........  ..........  ..........  ..........
                 deliver add-on.
01969.........  Anesth/analg cs hyst  ......  N       ..........  ..........  ..........  ..........  ..........
                 add-on.
01991.........  Anesth, nerve block/  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
01992.........  Anesth, n block/inj,  ......  N       ..........  ..........  ..........  ..........  ..........
                 prone.
01995.........  Regional anesthesia   CH....  D       ..........  ..........  ..........  ..........  ..........
                 limb.
01996.........  Hosp manage cont      ......  N       ..........  ..........  ..........  ..........  ..........
                 drug admin.
01999.........  Unlisted anesth       ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
10021.........  Fna w/o image.......  ......  T             0002      1.0995       67.58  ..........       13.52
10022.........  Fna w/image.........  ......  T             0036      2.0738      127.47  ..........       25.49

[[Page 68287]]

 
10040.........  Acne surgery........  ......  T             0010       0.476       29.26        8.02        5.85
10060.........  Drainage of skin      ......  T             0006      1.4392       88.46  ..........       17.69
                 abscess.
10061.........  Drainage of skin      ......  T             0006      1.4392       88.46  ..........       17.69
                 abscess.
10080.........  Drainage of           ......  T             0006      1.4392       88.46  ..........       17.69
                 pilonidal cyst.
10081.........  Drainage of           ......  T             0007     11.1535      685.58  ..........      137.12
                 pilonidal cyst.
10120.........  Remove foreign body.  ......  T             0006      1.4392       88.46  ..........       17.69
10121.........  Remove foreign body.  ......  T             0021     15.1024      928.31      219.48      185.66
10140.........  Drainage of hematoma/ ......  T             0007     11.1535      685.58  ..........      137.12
                 fluid.
10160.........  Puncture drainage of  ......  T             0018      1.0259       63.06       15.44       12.61
                 lesion.
10180.........  Complex drainage,     ......  T             0008     17.5086    1,076.22  ..........      215.24
                 wound.
11000.........  Debride infected      ......  T             0013      1.0918       67.11  ..........       13.42
                 skin.
11001.........  Debride infected      ......  T             0012      0.8432       51.83       11.18       10.37
                 skin add-on.
11010.........  Debride skin, fx....  ......  T             0019      4.0919      251.52       71.87       50.30
11011.........  Debride skin/muscle,  ......  T             0019      4.0919      251.52       71.87       50.30
                 fx.
11012.........  Debride skin/muscle/  ......  T             0019      4.0919      251.52       71.87       50.30
                 bone, fx.
11040.........  Debride skin,         ......  T             0015      1.6241       99.83       20.13       19.97
                 partial.
11041.........  Debride skin, full..  ......  T             0015      1.6241       99.83       20.13       19.97
11042.........  Debride skin/tissue.  ......  T             0016      2.6749      164.42  ..........       32.88
11043.........  Debride tissue/       ......  T             0016      2.6749      164.42  ..........       32.88
                 muscle.
11044.........  Debride tissue/       ......  T             0682      6.8832      423.10      158.65       84.62
                 muscle/bone.
11055.........  Trim skin lesion....  ......  T             0012      0.8432       51.83       11.18       10.37
11056.........  Trim skin lesions, 2  ......  T             0012      0.8432       51.83       11.18       10.37
                 to 4.
11057.........  Trim skin lesions,    ......  T             0013      1.0918       67.11  ..........       13.42
                 over 4.
11100.........  Biopsy, skin lesion.  ......  T             0018      1.0259       63.06       15.44       12.61
11101.........  Biopsy, skin add-on.  ......  T             0018      1.0259       63.06       15.44       12.61
11200.........  Removal of skin tags  ......  T             0013      1.0918       67.11  ..........       13.42
11201.........  Remove skin tags add- ......  T             0015      1.6241       99.83       20.13       19.97
                 on.
11300.........  Shave skin lesion...  ......  T             0012      0.8432       51.83       11.18       10.37
11301.........  Shave skin lesion...  ......  T             0012      0.8432       51.83       11.18       10.37
11302.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11303.........  Shave skin lesion...  ......  T             0015      1.6241       99.83       20.13       19.97
11305.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11306.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11307.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11308.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11310.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11311.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11312.........  Shave skin lesion...  ......  T             0013      1.0918       67.11  ..........       13.42
11313.........  Shave skin lesion...  ......  T             0016      2.6749      164.42  ..........       32.88
11400.........  Exc tr-ext b9+marg    ......  T             0019      4.0919      251.52       71.87       50.30
                 0.5 < cm.
11401.........  Exc tr-ext b9+marg    ......  T             0019      4.0919      251.52       71.87       50.30
                 0.6-1 cm.
11402.........  Exc tr-ext b9+marg    ......  T             0019      4.0919      251.52       71.87       50.30
                 1.1-2 cm.
11403.........  Exc tr-ext b9+marg    ......  T             0020      6.8083      418.49      107.67       83.70
                 2.1-3 cm.
11404.........  Exc tr-ext b9+marg    ......  T             0021     15.1024      928.31      219.48      185.66
                 3.1-4 cm.
11406.........  Exc tr-ext b9+marg >  ......  T             0021     15.1024      928.31      219.48      185.66
                 4.0 cm.
11420.........  Exc h-f-nk-sp         ......  T             0020      6.8083      418.49      107.67       83.70
                 b9+marg 0.5 <.
11421.........  Exc h-f-nk-sp         ......  T             0020      6.8083      418.49      107.67       83.70
                 b9+marg 0.6-1.
11422.........  Exc h-f-nk-sp         ......  T             0020      6.8083      418.49      107.67       83.70
                 b9+marg 1.1-2.
11423.........  Exc h-f-nk-sp         ......  T             0021     15.1024      928.31      219.48      185.66
                 b9+marg 2.1-3.
11424.........  Exc h-f-nk-sp         ......  T             0021     15.1024      928.31      219.48      185.66
                 b9+marg 3.1-4.
11426.........  Exc h-f-nk-sp         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 b9+marg > 4 cm.
11440.........  Exc face-mm b9+marg   ......  T             0019      4.0919      251.52       71.87       50.30
                 0.5 < cm.
11441.........  Exc face-mm b9+marg   ......  T             0019      4.0919      251.52       71.87       50.30
                 0.6-1 cm.
11442.........  Exc face-mm b9+marg   ......  T             0020      6.8083      418.49      107.67       83.70
                 1.1-2 cm.
11443.........  Exc face-mm b9+marg   ......  T             0020      6.8083      418.49      107.67       83.70
                 2.1-3 cm.
11444.........  Exc face-mm b9+marg   ......  T             0020      6.8083      418.49      107.67       83.70
                 3.1-4 cm.
11446.........  Exc face-mm b9+marg   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 > 4 cm.
11450.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11451.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11462.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11463.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11470.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11471.........  Removal, sweat gland  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11600.........  Exc tr-ext mlg+marg   ......  T             0019      4.0919      251.52       71.87       50.30
                 0.5 < cm.
11601.........  Exc tr-ext mlg+marg   ......  T             0019      4.0919      251.52       71.87       50.30
                 0.6-1 cm.
11602.........  Exc tr-ext mlg+marg   ......  T             0019      4.0919      251.52       71.87       50.30
                 1.1-2 cm.
11603.........  Exc tr-ext mlg+marg   ......  T             0020      6.8083      418.49      107.67       83.70
                 2.1-3 cm.
11604.........  Exc tr-ext mlg+marg   ......  T             0020      6.8083      418.49      107.67       83.70
                 3.1-4 cm.
11606.........  Exc tr-ext mlg+marg   ......  T             0021     15.1024      928.31      219.48      185.66
                 > 4 cm.
11620.........  Exc h-f-nk-sp         ......  T             0020      6.8083      418.49      107.67       83.70
                 mlg+marg 0.5 <.

[[Page 68288]]

 
11621.........  Exc h-f-nk-sp         ......  T             0019      4.0919      251.52       71.87       50.30
                 mlg+marg 0.6-1.
11622.........  Exc h-f-nk-sp         ......  T             0020      6.8083      418.49      107.67       83.70
                 mlg+marg 1.1-2.
11623.........  Exc h-f-nk-sp         ......  T             0021     15.1024      928.31      219.48      185.66
                 mlg+marg 2.1-3.
11624.........  Exc h-f-nk-sp         ......  T             0021     15.1024      928.31      219.48      185.66
                 mlg+marg 3.1-4.
11626.........  Exc h-f-nk-sp         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 mlg+mar > 4 cm.
11640.........  Exc face-mm           ......  T             0020      6.8083      418.49      107.67       83.70
                 malig+marg 0.5 <.
11641.........  Exc face-mm           ......  T             0020      6.8083      418.49      107.67       83.70
                 malig+marg 0.6-1.
11642.........  Exc face-mm           ......  T             0020      6.8083      418.49      107.67       83.70
                 malig+marg 1.1-2.
11643.........  Exc face-mm           ......  T             0020      6.8083      418.49      107.67       83.70
                 malig+marg 2.1-3.
11644.........  Exc face-mm           ......  T             0021     15.1024      928.31      219.48      185.66
                 malig+marg 3.1-4.
11646.........  Exc face-mm mlg+marg  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 > 4 cm.
11719.........  Trim nail(s)........  ......  T             0009      0.7744       47.60  ..........        9.52
11720.........  Debride nail, 1-5...  ......  T             0009      0.7744       47.60  ..........        9.52
11721.........  Debride nail, 6 or    ......  T             0009      0.7744       47.60  ..........        9.52
                 more.
11730.........  Removal of nail       ......  T             0013      1.0918       67.11  ..........       13.42
                 plate.
11732.........  Remove nail plate,    ......  T             0012      0.8432       51.83       11.18       10.37
                 add-on.
11740.........  Drain blood from      ......  T             0009      0.7744       47.60  ..........        9.52
                 under nail.
11750.........  Removal of nail bed.  ......  T             0019      4.0919      251.52       71.87       50.30
11752.........  Remove nail bed/      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 finger tip.
11755.........  Biopsy, nail unit...  ......  T             0019      4.0919      251.52       71.87       50.30
11760.........  Repair of nail bed..  ......  T             0024      1.4843       91.24       29.88       18.25
11762.........  Reconstruction of     ......  T             0024      1.4843       91.24       29.88       18.25
                 nail bed.
11765.........  Excision of nail      ......  T             0015      1.6241       99.83       20.13       19.97
                 fold, toe.
11770.........  Removal of pilonidal  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11771.........  Removal of pilonidal  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11772.........  Removal of pilonidal  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
11900.........  Injection into skin   ......  T             0012      0.8432       51.83       11.18       10.37
                 lesions.
11901.........  Added skin lesions    ......  T             0012      0.8432       51.83       11.18       10.37
                 injection.
11920.........  Correct skin color    ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11921.........  Correct skin color    ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11922.........  Correct skin color    ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11950.........  Therapy for contour   ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11951.........  Therapy for contour   ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11952.........  Therapy for contour   ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11954.........  Therapy for contour   ......  T             0024      1.4843       91.24       29.88       18.25
                 defects.
11960.........  Insert tissue         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 expander(s).
11970.........  Replace tissue        CH....  T             0051     41.0893    2,525.68  ..........      505.14
                 expander.
11971.........  Remove tissue         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 expander(s).
11976.........  Removal of            ......  T             0019      4.0919      251.52       71.87       50.30
                 contraceptive cap.
11980.........  Implant hormone       ......  X             0340      0.6102       37.51  ..........        7.50
                 pellet(s).
11981.........  Insert drug implant   ......  X             0340      0.6102       37.51  ..........        7.50
                 device.
11982.........  Remove drug implant   ......  X             0340      0.6102       37.51  ..........        7.50
                 device.
11983.........  Remove/insert drug    ......  X             0340      0.6102       37.51  ..........        7.50
                 implant.
12001.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12002.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12004.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12005.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12006.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12007.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12011.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12013.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12014.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12015.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12016.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12017.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12018.........  Repair superficial    ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12020.........  Closure of split      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound.
12021.........  Closure of split      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound.
12031.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12032.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12034.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12035.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12036.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12037.........  Layer closure of      ......  T             0025      5.2594      323.28      101.85       64.66
                 wound(s).
12041.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12042.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12044.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12045.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12046.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12047.........  Layer closure of      ......  T             0025      5.2594      323.28      101.85       64.66
                 wound(s).

[[Page 68289]]

 
12051.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12052.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12053.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12054.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12055.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12056.........  Layer closure of      ......  T             0024      1.4843       91.24       29.88       18.25
                 wound(s).
12057.........  Layer closure of      ......  T             0025      5.2594      323.28      101.85       64.66
                 wound(s).
13100.........  Repair of wound or    ......  T             0025      5.2594      323.28      101.85       64.66
                 lesion.
13101.........  Repair of wound or    ......  T             0025      5.2594      323.28      101.85       64.66
                 lesion.
13102.........  Repair wound/lesion   ......  T             0024      1.4843       91.24       29.88       18.25
                 add-on.
13120.........  Repair of wound or    ......  T             0024      1.4843       91.24       29.88       18.25
                 lesion.
13121.........  Repair of wound or    ......  T             0024      1.4843       91.24       29.88       18.25
                 lesion.
13122.........  Repair wound/lesion   ......  T             0024      1.4843       91.24       29.88       18.25
                 add-on.
13131.........  Repair of wound or    ......  T             0024      1.4843       91.24       29.88       18.25
                 lesion.
13132.........  Repair of wound or    ......  T             0024      1.4843       91.24       29.88       18.25
                 lesion.
13133.........  Repair wound/lesion   ......  T             0024      1.4843       91.24       29.88       18.25
                 add-on.
13150.........  Repair of wound or    ......  T             0025      5.2594      323.28      101.85       64.66
                 lesion.
13151.........  Repair of wound or    CH....  T             0025      5.2594      323.28      101.85       64.66
                 lesion.
13152.........  Repair of wound or    ......  T             0025      5.2594      323.28      101.85       64.66
                 lesion.
13153.........  Repair wound/lesion   ......  T             0024      1.4843       91.24       29.88       18.25
                 add-on.
13160.........  Late closure of       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wound.
14000.........  Skin tissue           ......  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14001.........  Skin tissue           ......  T             0027     21.4302    1,317.27      329.72      263.45
                 rearrangement.
14020.........  Skin tissue           ......  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14021.........  Skin tissue           CH....  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14040.........  Skin tissue           ......  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14041.........  Skin tissue           CH....  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14060.........  Skin tissue           CH....  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14061.........  Skin tissue           ......  T             0686     14.0346      862.68  ..........      172.54
                 rearrangement.
14300.........  Skin tissue           ......  T             0027     21.4302    1,317.27      329.72      263.45
                 rearrangement.
14350.........  Skin tissue           ......  T             0027     21.4302    1,317.27      329.72      263.45
                 rearrangement.
15000.........  Wound prep, 1st 100   CH....  D       ..........  ..........  ..........  ..........  ..........
                 sq cm.
15001.........  Wound prep, addl 100  CH....  D       ..........  ..........  ..........  ..........  ..........
                 sq cm.
15002.........  Wnd prep, ch/inf,     NI....  T             0025      5.2594      323.28      101.85       64.66
                 trk/arm/lg.
15003.........  Wnd prep, ch/inf      NI....  T             0025      5.2594      323.28      101.85       64.66
                 addl 100 cm.
15004.........  Wnd prep ch/inf, f/n/ NI....  T             0025      5.2594      323.28      101.85       64.66
                 hf/g.
15005.........  Wnd prep, f/n/hf/g,   NI....  T             0025      5.2594      323.28      101.85       64.66
                 addl cm.
15040.........  Harvest cultured      ......  T             0024      1.4843       91.24       29.88       18.25
                 skin graft.
15050.........  Skin pinch graft....  ......  T             0025      5.2594      323.28      101.85       64.66
15100.........  Skin splt grft, trnk/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 arm/leg.
15101.........  Skin splt grft t/a/   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 l, add-on.
15110.........  Epidrm autogrft trnk/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 arm/leg.
15111.........  Epidrm autogrft t/a/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 l add-on.
15115.........  Epidrm a-grft face/   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 nck/hf/g.
15116.........  Epidrm a-grft f/n/hf/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 g addl.
15120.........  Skn splt a-grft fac/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 nck/hf/g.
15121.........  Skn splt a-grft f/n/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 hf/g add.
15130.........  Derm autograft, trnk/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 arm/leg.
15131.........  Derm autograft t/a/l  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 add-on.
15135.........  Derm autograft face/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 nck/hf/g.
15136.........  Derm autograft, f/n/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 hf/g add.
15150.........  Cult epiderm grft t/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 arm/leg.
15151.........  Cult epiderm grft t/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 a/l addl.
15152.........  Cult epiderm graft t/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 a/l +%.
15155.........  Cult epiderm graft,   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 f/n/hf/g.
15156.........  Cult epidrm grft f/n/ ......  T             0027     21.4302    1,317.27      329.72      263.45
                 hfg add.
15157.........  Cult epiderm grft f/  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 n/hfg +%.
15170.........  Acell graft trunk/    CH....  T             0025      5.2594      323.28      101.85       64.66
                 arms/legs.
15171.........  Acell graft t/arm/    CH....  T             0025      5.2594      323.28      101.85       64.66
                 leg add-on.
15175.........  Acellular graft, f/n/ CH....  T             0025      5.2594      323.28      101.85       64.66
                 hf/g.
15176.........  Acell graft, f/n/hf/  CH....  T             0025      5.2594      323.28      101.85       64.66
                 g add-on.
15200.........  Skin full graft,      CH....  T             0686     14.0346      862.68  ..........      172.54
                 trunk.
15201.........  Skin full graft       ......  T             0025      5.2594      323.28      101.85       64.66
                 trunk add-on.
15220.........  Skin full graft sclp/ CH....  T             0686     14.0346      862.68  ..........      172.54
                 arm/leg.
15221.........  Skin full graft add-  ......  T             0025      5.2594      323.28      101.85       64.66
                 on.
15240.........  Skin full grft face/  ......  T             0686     14.0346      862.68  ..........      172.54
                 genit/hf.
15241.........  Skin full graft add-  ......  T             0025      5.2594      323.28      101.85       64.66
                 on.
15260.........  Skin full graft een   ......  T             0686     14.0346      862.68  ..........      172.54
                 & lips.
15261.........  Skin full graft add-  ......  T             0025      5.2594      323.28      101.85       64.66
                 on.
15300.........  Apply skinallogrft,   CH....  T             0025      5.2594      323.28      101.85       64.66
                 t/arm/lg.

[[Page 68290]]

 
15301.........  Apply sknallogrft t/  ......  T             0025      5.2594      323.28      101.85       64.66
                 a/l addl.
15320.........  Apply skin allogrft   ......  T             0025      5.2594      323.28      101.85       64.66
                 f/n/hf/g.
15321.........  Aply sknallogrft f/n/ ......  T             0025      5.2594      323.28      101.85       64.66
                 hfg add.
15330.........  Aply acell alogrft t/ ......  T             0025      5.2594      323.28      101.85       64.66
                 arm/leg.
15331.........  Aply acell grft t/a/  ......  T             0025      5.2594      323.28      101.85       64.66
                 l add-on.
15335.........  Apply acell graft, f/ ......  T             0025      5.2594      323.28      101.85       64.66
                 n/hf/g.
15336.........  Aply acell grft f/n/  ......  T             0025      5.2594      323.28      101.85       64.66
                 hf/g add.
15340.........  Apply cult skin       CH....  T             0025      5.2594      323.28      101.85       64.66
                 substitute.
15341.........  Apply cult skin sub   CH....  T             0025      5.2594      323.28      101.85       64.66
                 add-on.
15360.........  Apply cult derm sub,  CH....  T             0025      5.2594      323.28      101.85       64.66
                 t/a/l.
15361.........  Aply cult derm sub t/ CH....  T             0025      5.2594      323.28      101.85       64.66
                 a/l add.
15365.........  Apply cult derm sub   CH....  T             0025      5.2594      323.28      101.85       64.66
                 f/n/hf/g.
15366.........  Apply cult derm f/hf/ CH....  T             0025      5.2594      323.28      101.85       64.66
                 g add.
15400.........  Apply skin            ......  T             0025      5.2594      323.28      101.85       64.66
                 xenograft, t/a/l.
15401.........  Apply skn xenogrft t/ ......  T             0025      5.2594      323.28      101.85       64.66
                 a/l add.
15420.........  Apply skin xgraft, f/ ......  T             0025      5.2594      323.28      101.85       64.66
                 n/hf/g.
15421.........  Apply skn xgrft f/n/  ......  T             0025      5.2594      323.28      101.85       64.66
                 hf/g add.
15430.........  Apply acellular       ......  T             0025      5.2594      323.28      101.85       64.66
                 xenograft.
15431.........  Apply acellular       ......  T             0025      5.2594      323.28      101.85       64.66
                 xgraft add.
15570.........  Form skin pedicle     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 flap.
15572.........  Form skin pedicle     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 flap.
15574.........  Form skin pedicle     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 flap.
15576.........  Form skin pedicle     ......  T             0686     14.0346      862.68  ..........      172.54
                 flap.
15600.........  Skin graft..........  ......  T             0027     21.4302    1,317.27      329.72      263.45
15610.........  Skin graft..........  ......  T             0027     21.4302    1,317.27      329.72      263.45
15620.........  Skin graft..........  ......  T             0027     21.4302    1,317.27      329.72      263.45
15630.........  Skin graft..........  ......  T             0027     21.4302    1,317.27      329.72      263.45
15650.........  Transfer skin         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pedicle flap.
15731.........  Forehead flap w/vasc  NI....  T             0686     14.0346      862.68  ..........      172.54
                 pedicle.
15732.........  Muscle-skin graft,    ......  T             0027     21.4302    1,317.27      329.72      263.45
                 head/neck.
15734.........  Muscle-skin graft,    ......  T             0027     21.4302    1,317.27      329.72      263.45
                 trunk.
15736.........  Muscle-skin graft,    ......  T             0027     21.4302    1,317.27      329.72      263.45
                 arm.
15738.........  Muscle-skin graft,    ......  T             0027     21.4302    1,317.27      329.72      263.45
                 leg.
15740.........  Island pedicle flap   ......  T             0686     14.0346      862.68  ..........      172.54
                 graft.
15750.........  Neurovascular         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pedicle graft.
15760.........  Composite skin graft  ......  T             0027     21.4302    1,317.27      329.72      263.45
15770.........  Derma-fat-fascia      ......  T             0027     21.4302    1,317.27      329.72      263.45
                 graft.
15775.........  Hair transplant       ......  T             0025      5.2594      323.28      101.85       64.66
                 punch grafts.
15776.........  Hair transplant       ......  T             0025      5.2594      323.28      101.85       64.66
                 punch grafts.
15780.........  Abrasion treatment    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 of skin.
15781.........  Abrasion treatment    ......  T             0019      4.0919      251.52       71.87       50.30
                 of skin.
15782.........  Abrasion treatment    ......  T             0019      4.0919      251.52       71.87       50.30
                 of skin.
15783.........  Abrasion treatment    ......  T             0016      2.6749      164.42  ..........       32.88
                 of skin.
15786.........  Abrasion, lesion,     ......  T             0013      1.0918       67.11  ..........       13.42
                 single.
15787.........  Abrasion, lesions,    ......  T             0013      1.0918       67.11  ..........       13.42
                 add-on.
15788.........  Chemical peel, face,  ......  T             0012      0.8432       51.83       11.18       10.37
                 epiderm.
15789.........  Chemical peel, face,  ......  T             0015      1.6241       99.83       20.13       19.97
                 dermal.
15792.........  Chemical peel,        ......  T             0013      1.0918       67.11  ..........       13.42
                 nonfacial.
15793.........  Chemical peel,        ......  T             0012      0.8432       51.83       11.18       10.37
                 nonfacial.
15819.........  Plastic surgery,      ......  T             0025      5.2594      323.28      101.85       64.66
                 neck.
15820.........  Revision of lower     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 eyelid.
15821.........  Revision of lower     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 eyelid.
15822.........  Revision of upper     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 eyelid.
15823.........  Revision of upper     CH....  T             0686     14.0346      862.68  ..........      172.54
                 eyelid.
15824.........  Removal of forehead   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wrinkles.
15825.........  Removal of neck       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wrinkles.
15826.........  Removal of brow       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wrinkles.
15828.........  Removal of face       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wrinkles.
15829.........  Removal of skin       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 wrinkles.
15830.........  Exc skin abd........   NI...  T             0022     20.0656    1,233.39      354.45      246.68
15831.........  Excise excessive       CH...  D       ..........  ..........  ..........  ..........  ..........
                 skin tissue.
15832.........  Excise excessive      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 skin tissue.
15833.........  Excise excessive      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 skin tissue.
15834.........  Excise excessive      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 skin tissue.
15835.........  Excise excessive      ......  T             0025      5.2594      323.28      101.85       64.66
                 skin tissue.
15836.........  Excise excessive      ......  T             0021     15.1024      928.31      219.48      185.66
                 skin tissue.
15837.........  Excise excessive      ......  T             0021     15.1024      928.31      219.48      185.66
                 skin tissue.
15838.........  Excise excessive      ......  T             0021     15.1024      928.31      219.48      185.66
                 skin tissue.
15839.........  Excise excessive      ......  T             0021     15.1024      928.31      219.48      185.66
                 skin tissue.
15840.........  Graft for face nerve  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 palsy.

[[Page 68291]]

 
15841.........  Graft for face nerve  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 palsy.
15842.........  Flap for face nerve   ......  T             0686     14.0346      862.68  ..........      172.54
                 palsy.
15845.........  Skin and muscle       ......  T             0027     21.4302    1,317.27      329.72      263.45
                 repair, face.
15847.........  Exc skin abd add-on.   NI...  T             0022     20.0656    1,233.39      354.45      246.68
15850.........  Removal of sutures..  ......  T             0016      2.6749      164.42  ..........       32.88
15851.........  Removal of sutures..  ......  T             0016      2.6749      164.42  ..........       32.88
15852.........  Dressing change not   ......  X             0340      0.6102       37.51  ..........        7.50
                 for burn.
15860.........  Test for blood flow    CH...  X             0340      0.6102       37.51  ..........        7.50
                 in graft.
15876.........  Suction assisted      ......  T             0027     21.4302    1,317.27      329.72      263.45
                 lipectomy.
15877.........  Suction assisted      ......  T             0027     21.4302    1,317.27      329.72      263.45
                 lipectomy.
15878.........  Suction assisted      ......  T             0686     14.0346      862.68  ..........      172.54
                 lipectomy.
15879.........  Suction assisted      ......  T             0027     21.4302    1,317.27      329.72      263.45
                 lipectomy.
15920.........  Removal of tail bone  ......  T             0019      4.0919      251.52       71.87       50.30
                 ulcer.
15922.........  Removal of tail bone  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 ulcer.
15931.........  Remove sacrum         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 pressure sore.
15933.........  Remove sacrum         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 pressure sore.
15934.........  Remove sacrum         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15935.........  Remove sacrum         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15936.........  Remove sacrum         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15937.........  Remove sacrum         ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15940.........  Remove hip pressure   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 sore.
15941.........  Remove hip pressure   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 sore.
15944.........  Remove hip pressure   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 sore.
15945.........  Remove hip pressure   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 sore.
15946.........  Remove hip pressure   ......  T             0027     21.4302    1,317.27      329.72      263.45
                 sore.
15950.........  Remove thigh          ......  T             0022     20.0656    1,233.39      354.45      246.68
                 pressure sore.
15951.........  Remove thigh          ......  T             0022     20.0656    1,233.39      354.45      246.68
                 pressure sore.
15952.........  Remove thigh          ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15953.........  Remove thigh          ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15956.........  Remove thigh          ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15958.........  Remove thigh          ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pressure sore.
15999.........  Removal of pressure   ......  T             0019      4.0919      251.52       71.87       50.30
                 sore.
16000.........  Initial treatment of  ......  T             0012      0.8432       51.83       11.18       10.37
                 burn(s).
16020.........  Dress/debrid p-thick  ......  T             0013      1.0918       67.11  ..........       13.42
                 burn, s.
16025.........  Dress/debrid p-thick  ......  T             0013      1.0918       67.11  ..........       13.42
                 burn, m.
16030.........  Dress/debrid p-thick  ......  T             0015      1.6241       99.83       20.13       19.97
                 burn, l.
16035.........  Incision of burn       CH...  T             0016      2.6749      164.42  ..........       32.88
                 scab, initi.
17000.........  Destruct premalg      ......  T             0010       0.476       29.26        8.02        5.85
                 lesion.
17003.........  Destruct premalg      ......  T             0010       0.476       29.26        8.02        5.85
                 les, 2-14.
17004.........  Destroy premlg        ......  T             0011      2.5665      157.76  ..........       31.55
                 lesions 15+.
17106.........  Destruction of skin   ......  T             0011      2.5665      157.76  ..........       31.55
                 lesions.
17107.........  Destruction of skin   ......  T             0011      2.5665      157.76  ..........       31.55
                 lesions.
17108.........  Destruction of skin   ......  T             0011      2.5665      157.76  ..........       31.55
                 lesions.
17110.........  Destruct b9 lesion,    CH...  T             0012      0.8432       51.83       11.18       10.37
                 1-14.
17111.........  Destruct lesion, 15   ......  T             0013      1.0918       67.11  ..........       13.42
                 or more.
17250.........  Chemical cautery,     ......  T             0013      1.0918       67.11  ..........       13.42
                 tissue.
17260.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17261.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17262.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17263.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17264.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17266.........  Destruction of skin   ......  T             0016      2.6749      164.42  ..........       32.88
                 lesions.
17270.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17271.........  Destruction of skin   ......  T             0013      1.0918       67.11  ..........       13.42
                 lesions.
17272.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17273.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17274.........  Destruction of skin   ......  T             0016      2.6749      164.42  ..........       32.88
                 lesions.
17276.........  Destruction of skin   ......  T             0016      2.6749      164.42  ..........       32.88
                 lesions.
17280.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17281.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17282.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17283.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17284.........  Destruction of skin   ......  T             0016      2.6749      164.42  ..........       32.88
                 lesions.
17286.........  Destruction of skin   ......  T             0015      1.6241       99.83       20.13       19.97
                 lesions.
17304.........  1 stage mohs, up to    CH...  D       ..........  ..........  ..........  ..........  ..........
                 5 spec.
17305.........  2 stage mohs, up to    CH...  D       ..........  ..........  ..........  ..........  ..........
                 5 spec.
17306.........  3 stage mohs, up to    CH...  D       ..........  ..........  ..........  ..........  ..........
                 5 spec.
17307.........  Mohs addl stage up     CH...  D       ..........  ..........  ..........  ..........  ..........
                 to 5 spec.
17310.........  Mohs any stage > 5     CH...  D       ..........  ..........  ..........  ..........  ..........
                 spec each.
17311.........  Mohs, 1 stage, h/n/    NI...  T             0694      3.7292      229.23       91.69       45.85
                 hf/g.

[[Page 68292]]

 
17312.........  Mohs addl stage.....   NI...  T             0694      3.7292      229.23       91.69       45.85
17313.........  Mohs, 1 stage, t/a/l   NI...  T             0694      3.7292      229.23       91.69       45.85
17314.........  Mohs, addl stage, t/   NI...  T             0694      3.7292      229.23       91.69       45.85
                 a/l.
17315.........  Mohs surg, addl        NI...  T             0694      3.7292      229.23       91.69       45.85
                 block.
17340.........  Cryotherapy of skin.   CH...  T             0016      2.6749      164.42  ..........       32.88
17360.........  Skin peel therapy...  ......  T             0013      1.0918       67.11  ..........       13.42
17380.........  Hair removal by       ......  T             0013      1.0918       67.11  ..........       13.42
                 electrolysis.
17999.........  Skin tissue            CH...  T             0012      0.8432       51.83       11.18       10.37
                 procedure.
19000.........  Drainage of breast    ......  T             0004      2.0687      127.16  ..........       25.43
                 lesion.
19001.........  Drain breast lesion    CH...  T             0002      1.0995       67.58  ..........       13.52
                 add-on.
19020.........  Incision of breast    ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
19030.........  Injection for breast  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
19100.........  Bx breast percut w/o  ......  T             0005      3.9045      240.00       71.59       48.00
                 image.
19101.........  Biopsy of breast,     ......  T             0028     19.2788    1,185.03      303.74      237.01
                 open.
19102.........  Bx breast percut w/   ......  T             0005      3.9045      240.00       71.59       48.00
                 image.
19103.........  Bx breast percut w/   ......  T             0658      6.4387      395.77  ..........       79.15
                 device.
19105.........  Cryosurg ablate fa,    NI...  T             0029     28.0166    1,722.12      581.52      344.42
                 each.
19110.........  Nipple exploration..  ......  T             0028     19.2788    1,185.03      303.74      237.01
19112.........  Excise breast duct    ......  T             0028     19.2788    1,185.03      303.74      237.01
                 fistula.
19120.........  Removal of breast     ......  T             0028     19.2788    1,185.03      303.74      237.01
                 lesion.
19125.........  Excision, breast      ......  T             0028     19.2788    1,185.03      303.74      237.01
                 lesion.
19126.........  Excision, addl        ......  T             0028     19.2788    1,185.03      303.74      237.01
                 breast lesion.
19140.........  Removal of breast      CH...  D       ..........  ..........  ..........  ..........  ..........
                 tissue.
19160.........  Partial mastectomy..   CH...  D       ..........  ..........  ..........  ..........  ..........
19162.........  P-mastectomy w/ln      CH...  D       ..........  ..........  ..........  ..........  ..........
                 removal.
19180.........  Removal of breast...   CH...  D       ..........  ..........  ..........  ..........  ..........
19182.........  Removal of breast...   CH...  D       ..........  ..........  ..........  ..........  ..........
19200.........  Removal of breast...   CH...  D       ..........  ..........  ..........  ..........  ..........
19220.........  Removal of breast...   CH...  D       ..........  ..........  ..........  ..........  ..........
19240.........  Removal of breast...   CH...  D       ..........  ..........  ..........  ..........  ..........
19260.........  Removal of chest      ......  T             0021     15.1024      928.31      219.48      185.66
                 wall lesion.
19290.........  Place needle wire,    ......  N       ..........  ..........  ..........  ..........  ..........
                 breast.
19291.........  Place needle wire,    ......  N       ..........  ..........  ..........  ..........  ..........
                 breast.
19295.........  Place breast clip,    ......  S             0657      1.7369      106.76  ..........       21.35
                 percut.
19296.........  Place po breast cath   CH...  T             0648     51.2269    3,148.82  ..........      629.76
                 for rad.
19297.........  Place breast cath      CH...  T             0648     51.2269    3,148.82  ..........      629.76
                 for rad.
19298.........  Place breast rad      ......  S             1524  ..........    3,250.00  ..........      650.00
                 tube/caths.
19300.........  Removal of breast      NI...  T             0028     19.2788    1,185.03      303.74      237.01
                 tissue.
19301.........  Partical mastectomy.   NI...  T             0028     19.2788    1,185.03      303.74      237.01
19302.........  P-mastectomy w/ln      NI...  T             0693     36.9988    2,274.24      721.30      454.85
                 removal.
19303.........  Mast, simple,          NI...  T             0029     28.0166    1,722.12      581.52      344.42
                 complete.
19304.........  Mast, subq..........   NI...  T             0029     28.0166    1,722.12      581.52      344.42
19305.........  Mast, radical.......   NI...  C       ..........  ..........  ..........  ..........  ..........
19306.........  Mast, rad, urban       NI...  C       ..........  ..........  ..........  ..........  ..........
                 type.
19307.........  Mast, mod rad.......   NI...  T             0030     37.8692    2,327.74      747.07      465.55
19316.........  Suspension of breast  ......  T             0029     28.0166    1,722.12      581.52      344.42
19318.........  Reduction of large    ......  T             0693     36.9988    2,274.24      721.30      454.85
                 breast.
19324.........  Enlarge breast......  ......  T             0693     36.9988    2,274.24      721.30      454.85
19325.........  Enlarge breast with   ......  T             0648     51.2269    3,148.82  ..........      629.76
                 implant.
19328.........  Removal of breast     ......  T             0029     28.0166    1,722.12      581.52      344.42
                 implant.
19330.........  Removal of implant    ......  T             0029     28.0166    1,722.12      581.52      344.42
                 material.
19340.........  Immediate breast      ......  T             0030     37.8692    2,327.74      747.07      465.55
                 prosthesis.
19342.........  Delayed breast        ......  T             0648     51.2269    3,148.82  ..........      629.76
                 prosthesis.
19350.........  Breast                ......  T             0028     19.2788    1,185.03      303.74      237.01
                 reconstruction.
19355.........  Correct inverted      ......  T             0029     28.0166    1,722.12      581.52      344.42
                 nipple(s).
19357.........  Breast                ......  T             0648     51.2269    3,148.82  ..........      629.76
                 reconstruction.
19366.........  Breast                ......  T             0029     28.0166    1,722.12      581.52      344.42
                 reconstruction.
19370.........  Surgery of breast     ......  T             0029     28.0166    1,722.12      581.52      344.42
                 capsule.
19371.........  Removal of breast     ......  T             0029     28.0166    1,722.12      581.52      344.42
                 capsule.
19380.........  Revise breast         ......  T             0030     37.8692    2,327.74      747.07      465.55
                 reconstruction.
19396.........  Design custom breast  ......  T             0029     28.0166    1,722.12      581.52      344.42
                 implant.
19499.........  Breast surgery        ......  T             0028     19.2788    1,185.03      303.74      237.01
                 procedure.
20000.........  Incision of abscess.  ......  T             0006      1.4392       88.46  ..........       17.69
20005.........  Incision of deep      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 abscess.
20100.........  Explore wound, neck.  ......  T             0023      4.2212      259.47  ..........       51.89
20101.........  Explore wound, chest  ......  T             0027     21.4302    1,317.27      329.72      263.45
20102.........  Explore wound,        ......  T             0027     21.4302    1,317.27      329.72      263.45
                 abdomen.
20103.........  Explore wound,        ......  T             0023      4.2212      259.47  ..........       51.89
                 extremity.
20150.........  Excise epiphyseal     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 bar.
20200.........  Muscle biopsy.......  ......  T             0021     15.1024      928.31      219.48      185.66

[[Page 68293]]

 
20205.........  Deep muscle biopsy..  ......  T             0021     15.1024      928.31      219.48      185.66
20206.........  Needle biopsy,        ......  T             0005      3.9045      240.00       71.59       48.00
                 muscle.
20220.........  Bone biopsy, trocar/  ......  T             0019      4.0919      251.52       71.87       50.30
                 needle.
20225.........  Bone biopsy, trocar/  ......  T             0020      6.8083      418.49      107.67       83.70
                 needle.
20240.........  Bone biopsy,          ......  T             0022     20.0656    1,233.39      354.45      246.68
                 excisional.
20245.........  Bone biopsy,          ......  T             0022     20.0656    1,233.39      354.45      246.68
                 excisional.
20250.........  Open bone biopsy....  ......  T             0049     20.8706    1,282.87  ..........      256.57
20251.........  Open bone biopsy....  ......  T             0049     20.8706    1,282.87  ..........      256.57
20500.........  Injection of sinus    ......  T             0251       2.452      150.72  ..........       30.14
                 tract.
20501.........  Inject sinus tract    ......  N       ..........  ..........  ..........  ..........  ..........
                 for x-ray.
20520.........  Removal of foreign    ......  T             0019      4.0919      251.52       71.87       50.30
                 body.
20525.........  Removal of foreign    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 body.
20526.........  Ther injection, carp  ......  T             0204      2.2614      139.00       40.13       27.80
                 tunnel.
20550.........  Inj tendon sheath/    ......  T             0204      2.2614      139.00       40.13       27.80
                 ligament.
20551.........  Inj tendon origin/    ......  T             0204      2.2614      139.00       40.13       27.80
                 insertion.
20552.........  Inj trigger point, 1/ ......  T             0204      2.2614      139.00       40.13       27.80
                 2 muscl.
20553.........  Inject trigger        ......  T             0204      2.2614      139.00       40.13       27.80
                 points, [gE] 3.
20600.........  Drain/inject, joint/  ......  T             0204      2.2614      139.00       40.13       27.80
                 bursa.
20605.........  Drain/inject, joint/  ......  T             0204      2.2614      139.00       40.13       27.80
                 bursa.
20610.........  Drain/inject, joint/  ......  T             0204      2.2614      139.00       40.13       27.80
                 bursa.
20612.........  Aspirate/inj          ......  T             0204      2.2614      139.00       40.13       27.80
                 ganglion cyst.
20615.........  Treatment of bone     ......  T             0004      2.0687      127.16  ..........       25.43
                 cyst.
20650.........  Insert and remove     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bone pin.
20662.........  Application of        ......  T             0049     20.8706    1,282.87  ..........      256.57
                 pelvis brace.
20663.........  Application of thigh  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 brace.
20665.........  Removal of fixation   ......  X             0340      0.6102       37.51  ..........        7.50
                 device.
20670.........  Removal of support    ......  T             0021     15.1024      928.31      219.48      185.66
                 implant.
20680.........  Removal of support    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 implant.
20690.........  Apply bone fixation   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 device.
20692.........  Apply bone fixation   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 device.
20693.........  Adjust bone fixation  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 device.
20694.........  Remove bone fixation  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 device.
20822.........  Replantation digit,   ......  T             0054     25.8758    1,590.53  ..........      318.11
                 complete.
20900.........  Removal of bone for   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 graft.
20902.........  Removal of bone for   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 graft.
20910.........  Remove cartilage for  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 graft.
20912.........  Remove cartilage for  ......  T             0027     21.4302    1,317.27      329.72      263.45
                 graft.
20920.........  Removal of fascia     ......  T             0686     14.0346      862.68  ..........      172.54
                 for graft.
20922.........  Removal of fascia     ......  T             0027     21.4302    1,317.27      329.72      263.45
                 for graft.
20924.........  Removal of tendon     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 for graft.
20926.........  Removal of tissue     ......  T             0686     14.0346      862.68  ..........      172.54
                 for graft.
20950.........  Fluid pressure,       ......  T             0006      1.4392       88.46  ..........       17.69
                 muscle.
20972.........  Bone/skin graft,      ......  T             0056     40.8559    2,511.33  ..........      502.27
                 metatarsal.
20973.........  Bone/skin graft,      ......  T             0056     40.8559    2,511.33  ..........      502.27
                 great toe.
20975.........  Electrical bone       ......  X             0340      0.6102       37.51  ..........        7.50
                 stimulation.
20979.........  Us bone stimulation.  ......  X             0340      0.6102       37.51  ..........        7.50
20982.........  Ablate, bone           CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 tumor(s) perq.
20999.........  Musculoskeletal       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 surgery.
21010.........  Incision of jaw       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 joint.
21015.........  Resection of facial   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 tumor.
21025.........  Excision of bone,     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lower jaw.
21026.........  Excision of facial    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bone(s).
21029.........  Contour of face bone  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
21030.........  Excise max/zygoma b9  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 tumor.
21031.........  Remove exostosis,     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 mandible.
21032.........  Remove exostosis,     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 maxilla.
21034.........  Excise max/zygoma     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mlg tumor.
21040.........  Excise mandible       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
21044.........  Removal of jaw bone   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
21046.........  Remove mandible cyst  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 complex.
21047.........  Excise lwr jaw cyst   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 w/repair.
21048.........  Remove maxilla cyst   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 complex.
21049.........  Excis uppr jaw cyst   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 w/repair.
21050.........  Removal of jaw joint  ......  T             0256     38.1991    2,348.02  ..........      469.60
21060.........  Remove jaw joint      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 cartilage.
21070.........  Remove coronoid       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 process.
21076.........  Prepare face/oral     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 prosthesis.
21077.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21079.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21080.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.

[[Page 68294]]

 
21081.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21082.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21083.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21084.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21085.........  Prepare face/oral     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 prosthesis.
21086.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21087.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21088.........  Prepare face/oral     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 prosthesis.
21089.........  Prepare face/oral     ......  T             0251       2.452      150.72  ..........       30.14
                 prosthesis.
21100.........  Maxillofacial         ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fixation.
21110.........  Interdental fixation  ......  T             0252      7.5511      464.15      109.16       92.83
21116.........  Injection, jaw joint  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
21120.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 chin.
21121.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 chin.
21122.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 chin.
21123.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 chin.
21125.........  Augmentation, lower   ......  T             0254     23.3299    1,434.04      321.35      286.81
                 jaw bone.
21127.........  Augmentation, lower   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw bone.
21137.........  Reduction of          ......  T             0254     23.3299    1,434.04      321.35      286.81
                 forehead.
21138.........  Reduction of          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 forehead.
21139.........  Reduction of          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 forehead.
21150.........  Reconstruct midface,  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lefort.
21175.........  Reconstruct orbit/    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 forehead.
21181.........  Contour cranial bone  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
21195.........  Reconst lwr jaw w/o   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fixation.
21198.........  Reconstr lwr jaw      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 segment.
21199.........  Reconstr lwr jaw w/   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 advance.
21206.........  Reconstruct upper     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw bone.
21208.........  Augmentation of       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 facial bones.
21209.........  Reduction of facial   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bones.
21210.........  Face bone graft.....  ......  T             0256     38.1991    2,348.02  ..........      469.60
21215.........  Lower jaw bone graft  ......  T             0256     38.1991    2,348.02  ..........      469.60
21230.........  Rib cartilage graft.  ......  T             0256     38.1991    2,348.02  ..........      469.60
21235.........  Ear cartilage graft.  ......  T             0254     23.3299    1,434.04      321.35      286.81
21240.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw joint.
21242.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw joint.
21243.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw joint.
21244.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lower jaw.
21245.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw.
21246.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw.
21248.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw.
21249.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw.
21260.........  Revise eye sockets..  ......  T             0256     38.1991    2,348.02  ..........      469.60
21261.........  Revise eye sockets..  ......  T             0256     38.1991    2,348.02  ..........      469.60
21263.........  Revise eye sockets..  ......  T             0256     38.1991    2,348.02  ..........      469.60
21267.........  Revise eye sockets..  ......  T             0256     38.1991    2,348.02  ..........      469.60
21270.........  Augmentation, cheek   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bone.
21275.........  Revision,             ......  T             0256     38.1991    2,348.02  ..........      469.60
                 orbitofacial bones.
21280.........  Revision of eyelid..  ......  T             0256     38.1991    2,348.02  ..........      469.60
21282.........  Revision of eyelid..  ......  T             0253     16.4266    1,009.71      282.29      201.94
21295.........  Revision of jaw       ......  T             0252      7.5511      464.15      109.16       92.83
                 muscle/bone.
21296.........  Revision of jaw       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 muscle/bone.
21299.........  Cranio/maxillofacial  ......  T             0251       2.452      150.72  ..........       30.14
                 surgery.
21300.........  Treatment of skull     CH...  D       ..........  ..........  ..........  ..........  ..........
                 fracture.
21310.........  Treatment of nose     ......  T             0251       2.452      150.72  ..........       30.14
                 fracture.
21315.........  Treatment of nose     ......  T             0251       2.452      150.72  ..........       30.14
                 fracture.
21320.........  Treatment of nose     ......  T             0252      7.5511      464.15      109.16       92.83
                 fracture.
21325.........  Treatment of nose     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21330.........  Treatment of nose     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21335.........  Treatment of nose     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21336.........  Treat nasal septal     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
21337.........  Treat nasal septal    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 fracture.
21338.........  Treat nasoethmoid     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21339.........  Treat nasoethmoid     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21340.........  Treatment of nose     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21345.........  Treat nose/jaw        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21355.........  Treat cheek bone      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21356.........  Treat cheek bone      ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21390.........  Treat eye socket      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21400.........  Treat eye socket      ......  T             0252      7.5511      464.15      109.16       92.83
                 fracture.

[[Page 68295]]

 
21401.........  Treat eye socket      ......  T             0253     16.4266    1,009.71      282.29      201.94
                 fracture.
21406.........  Treat eye socket      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21407.........  Treat eye socket      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21408.........  Treat eye socket      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21421.........  Treat mouth roof      ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21440.........  Treat dental ridge    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21445.........  Treat dental ridge    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21450.........  Treat lower jaw       ......  T             0251       2.452      150.72  ..........       30.14
                 fracture.
21451.........  Treat lower jaw       ......  T             0252      7.5511      464.15      109.16       92.83
                 fracture.
21452.........  Treat lower jaw       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 fracture.
21453.........  Treat lower jaw       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21454.........  Treat lower jaw       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fracture.
21461.........  Treat lower jaw       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21462.........  Treat lower jaw       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21465.........  Treat lower jaw       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21470.........  Treat lower jaw       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fracture.
21480.........  Reset dislocated jaw  ......  T             0251       2.452      150.72  ..........       30.14
21485.........  Reset dislocated jaw  ......  T             0253     16.4266    1,009.71      282.29      201.94
21490.........  Repair dislocated     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 jaw.
21495.........  Treat hyoid bone      ......  T             0253     16.4266    1,009.71      282.29      201.94
                 fracture.
21497.........  Interdental wiring..  ......  T             0253     16.4266    1,009.71      282.29      201.94
21499.........  Head surgery          ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
21501.........  Drain neck/chest      ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
21502.........  Drain chest lesion..  ......  T             0049     20.8706    1,282.87  ..........      256.57
21550.........  Biopsy of neck/chest   CH...  T             0020      6.8083      418.49      107.67       83.70
21555.........  Remove lesion, neck/  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 chest.
21556.........  Remove lesion, neck/  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 chest.
21557.........  Remove tumor, neck/   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 chest.
21600.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 rib.
21610.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 rib.
21685.........  Hyoid myotomy &       ......  T             0252      7.5511      464.15      109.16       92.83
                 suspension.
21700.........  Revision of neck      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 muscle.
21720.........  Revision of neck      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 muscle.
21725.........  Revision of neck      ......  T             0006      1.4392       88.46  ..........       17.69
                 muscle.
21742.........  Repair stern/nuss w/  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 o scope.
21743.........  Repair sternum/nuss   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 w/scope.
21800.........  Treatment of rib      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
21805.........  Treatment of rib       CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
21820.........  Treat sternum         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
21899.........  Neck/chest surgery    ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
21920.........  Biopsy soft tissue    ......  T             0020      6.8083      418.49      107.67       83.70
                 of back.
21925.........  Biopsy soft tissue    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 of back.
21930.........  Remove lesion, back   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 or flank.
21935.........  Remove tumor, back..  ......  T             0022     20.0656    1,233.39      354.45      246.68
22100.........  Remove part of neck   ......  T             0208     44.1489    2,713.74  ..........      542.75
                 vertebra.
22101.........  Remove part, thorax   ......  T             0208     44.1489    2,713.74  ..........      542.75
                 vertebra.
22102.........  Remove part, lumbar   ......  T             0208     44.1489    2,713.74  ..........      542.75
                 vertebra.
22103.........  Remove extra spine    ......  T             0208     44.1489    2,713.74  ..........      542.75
                 segment.
22222.........  Revision of thorax    ......  T             0208     44.1489    2,713.74  ..........      542.75
                 spine.
22305.........  Treat spine process   ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
22310.........  Treat spine fracture  ......  T             0043      1.6857      103.62  ..........       20.72
22315.........  Treat spine fracture  ......  T             0043      1.6857      103.62  ..........       20.72
22505.........  Manipulation of       ......  T             0045     14.5947      897.11      268.47      179.42
                 spine.
22520.........  Percut                ......  T             0050     25.1296    1,544.67  ..........      308.93
                 vertebroplasty thor.
22521.........  Percut                ......  T             0050     25.1296    1,544.67  ..........      308.93
                 vertebroplasty lumb.
22522.........  Percut                ......  T             0050     25.1296    1,544.67  ..........      308.93
                 vertebroplasty
                 add[AElig]l.
22523.........  Percut kyphoplasty,   ......  T             0052       66.58    4,092.54  ..........      818.51
                 thor.
22524.........  Percut kyphoplasty,   ......  T             0052       66.58    4,092.54  ..........      818.51
                 lumbar.
22525.........  Percut kyphoplasty,   ......  T             0052       66.58    4,092.54  ..........      818.51
                 add-on.
22526.........  Idet, single level..   NI...  T             0050     25.1296    1,544.67  ..........      308.93
22527.........  Idet, 1 or more        NI...  T             0050     25.1296    1,544.67  ..........      308.93
                 levels.
22612.........  Lumbar spine fusion.  ......  T             0208     44.1489    2,713.74  ..........      542.75
22614.........  Spine fusion, extra   ......  T             0208     44.1489    2,713.74  ..........      542.75
                 segment.
22851.........  Apply spine prosth     CH...  T             0049     20.8706    1,282.87  ..........      256.57
                 device.
22857.........  Lumbar artif           NI...  C       ..........  ..........  ..........  ..........  ..........
                 diskectomy.
22862.........  Revise lumbar artif    NI...  C       ..........  ..........  ..........  ..........  ..........
                 disc.
22865.........  Remove lumb artif      NI...  C       ..........  ..........  ..........  ..........  ..........
                 disc.
22899.........  Spine surgery          CH...  T             0049     20.8706    1,282.87  ..........      256.57
                 procedure.
22900.........  Remove abdominal      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 wall lesion.
22999.........  Abdomen surgery        CH...  T             0049     20.8706    1,282.87  ..........      256.57
                 procedure.

[[Page 68296]]

 
23000.........  Removal of calcium    ......  T             0021     15.1024      928.31      219.48      185.66
                 deposits.
23020.........  Release shoulder      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
23030.........  Drain shoulder        ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
23031.........  Drain shoulder bursa  ......  T             0008     17.5086    1,076.22  ..........      215.24
23035.........  Drain shoulder bone   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
23040.........  Exploratory shoulder  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 surgery.
23044.........  Exploratory shoulder  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 surgery.
23065.........  Biopsy shoulder        CH...  T             0020      6.8083      418.49      107.67       83.70
                 tissues.
23066.........  Biopsy shoulder       ......  T             0022     20.0656    1,233.39      354.45      246.68
                 tissues.
23075.........  Removal of shoulder   ......  T             0021     15.1024      928.31      219.48      185.66
                 lesion.
23076.........  Removal of shoulder   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
23077.........  Remove tumor of       ......  T             0022     20.0656    1,233.39      354.45      246.68
                 shoulder.
23100.........  Biopsy of shoulder    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 joint.
23101.........  Shoulder joint        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 surgery.
23105.........  Remove shoulder       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint lining.
23106.........  Incision of           ......  T             0050     25.1296    1,544.67  ..........      308.93
                 collarbone joint.
23107.........  Explore treat         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 shoulder joint.
23120.........  Partial removal,      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 collar bone.
23125.........  Removal of collar     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 bone.
23130.........  Remove shoulder       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 bone, part.
23140.........  Removal of bone       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
23145.........  Removal of bone       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23146.........  Removal of bone       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23150.........  Removal of humerus    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23155.........  Removal of humerus    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23156.........  Removal of humerus    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23170.........  Remove collar bone    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23172.........  Remove shoulder       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 blade lesion.
23174.........  Remove humerus        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23180.........  Remove collar bone    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23182.........  Remove shoulder       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 blade lesion.
23184.........  Remove humerus        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
23190.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 scapula.
23195.........  Removal of head of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 humerus.
23330.........  Remove shoulder       ......  T             0020      6.8083      418.49      107.67       83.70
                 foreign body.
23331.........  Remove shoulder       ......  T             0022     20.0656    1,233.39      354.45      246.68
                 foreign body.
23350.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 shoulder x-ray.
23395.........  Muscle                ......  T             0051     41.0893    2,525.68  ..........      505.14
                 transfer,shoulder/
                 arm.
23397.........  Muscle transfers....  ......  T             0052       66.58    4,092.54  ..........      818.51
23400.........  Fixation of shoulder  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 blade.
23405.........  Incision of tendon &  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 muscle.
23406.........  Incise tendon(s) &    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 muscle(s).
23410.........  Repair rotator cuff,   CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 acute.
23412.........  Repair rotator cuff,   CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 chronic.
23415.........  Release of shoulder   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ligament.
23420.........  Repair of shoulder..   CH...  T             0051     41.0893    2,525.68  ..........      505.14
23430.........  Repair biceps tendon   CH...  T             0051     41.0893    2,525.68  ..........      505.14
23440.........  Remove/transplant      CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
23450.........  Repair shoulder       ......  T             0052       66.58    4,092.54  ..........      818.51
                 capsule.
23455.........  Repair shoulder       ......  T             0052       66.58    4,092.54  ..........      818.51
                 capsule.
23460.........  Repair shoulder       ......  T             0052       66.58    4,092.54  ..........      818.51
                 capsule.
23462.........  Repair shoulder        CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 capsule.
23465.........  Repair shoulder       ......  T             0052       66.58    4,092.54  ..........      818.51
                 capsule.
23466.........  Repair shoulder        CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 capsule.
23470.........  Reconstruct shoulder  ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
                 joint.
23480.........  Revision of collar    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 bone.
23485.........  Revision of collar     CH...  T             0052       66.58    4,092.54  ..........      818.51
                 bone.
23490.........  Reinforce clavicle..  ......  T             0051     41.0893    2,525.68  ..........      505.14
23491.........  Reinforce shoulder     CH...  T             0052       66.58    4,092.54  ..........      818.51
                 bones.
23500.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23505.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23515.........  Treat clavicle         CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23520.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
23525.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
23530.........  Treat clavicle         CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
23532.........  Treat clavicle         CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
23540.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
23545.........  Treat clavicle        ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
23550.........  Treat clavicle         CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
23552.........  Treat clavicle         CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.

[[Page 68297]]

 
23570.........  Treat shoulder blade  ......  T             0043      1.6857      103.62  ..........       20.72
                 fx.
23575.........  Treat shoulder blade  ......  T             0043      1.6857      103.62  ..........       20.72
                 fx.
23585.........  Treat scapula          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23600.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23605.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23615.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23616.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23620.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23625.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23630.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23650.........  Treat shoulder        ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
23655.........  Treat shoulder        ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
23660.........  Treat shoulder         CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
23665.........  Treat dislocation/    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23670.........  Treat dislocation/     CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
23675.........  Treat dislocation/    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
23680.........  Treat dislocation/     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
23700.........  Fixation of shoulder  ......  T             0045     14.5947      897.11      268.47      179.42
23800.........  Fusion of shoulder     CH...  T             0052       66.58    4,092.54  ..........      818.51
                 joint.
23802.........  Fusion of shoulder    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
23921.........  Amputation follow-up  ......  T             0025      5.2594      323.28      101.85       64.66
                 surgery.
23929.........  Shoulder surgery      ......  T             0043      1.6857      103.62  ..........       20.72
                 procedure.
23930.........  Drainage of arm       ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
23931.........  Drainage of arm       ......  T             0008     17.5086    1,076.22  ..........      215.24
                 bursa.
23935.........  Drain arm/elbow bone  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
24000.........  Exploratory elbow     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 surgery.
24006.........  Release elbow joint.  ......  T             0050     25.1296    1,544.67  ..........      308.93
24065.........  Biopsy arm/elbow      ......  T             0021     15.1024      928.31      219.48      185.66
                 soft tissue.
24066.........  Biopsy arm/elbow      ......  T             0021     15.1024      928.31      219.48      185.66
                 soft tissue.
24075.........  Remove arm/elbow      ......  T             0021     15.1024      928.31      219.48      185.66
                 lesion.
24076.........  Remove arm/elbow      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
24077.........  Remove tumor of arm/  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 elbow.
24100.........  Biopsy elbow joint    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lining.
24101.........  Explore/treat elbow   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
24102.........  Remove elbow joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
24105.........  Removal of elbow      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
24110.........  Remove humerus        ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
24115.........  Remove/graft bone     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24116.........  Remove/graft bone     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24120.........  Remove elbow lesion.  ......  T             0049     20.8706    1,282.87  ..........      256.57
24125.........  Remove/graft bone     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24126.........  Remove/graft bone     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24130.........  Removal of head of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 radius.
24134.........  Removal of arm bone   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24136.........  Remove radius bone    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24138.........  Remove elbow bone     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
24140.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 arm bone.
24145.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 radius.
24147.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24149.........  Radical resection of  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24150.........  Extensive humerus      CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 surgery.
24151.........  Extensive humerus     ......  T             0052       66.58    4,092.54  ..........      818.51
                 surgery.
24152.........  Extensive radius       CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 surgery.
24153.........  Extensive radius      ......  T             0052       66.58    4,092.54  ..........      818.51
                 surgery.
24155.........  Removal of elbow      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
24160.........  Remove elbow joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 implant.
24164.........  Remove radius head    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 implant.
24200.........  Removal of arm        ......  T             0019      4.0919      251.52       71.87       50.30
                 foreign body.
24201.........  Removal of arm        ......  T             0021     15.1024      928.31      219.48      185.66
                 foreign body.
24220.........  Injection for elbow   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
24300.........  Manipulate elbow w/   ......  T             0045     14.5947      897.11      268.47      179.42
                 anesth.
24301.........  Muscle/tendon         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 transfer.
24305.........  Arm tendon            ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lengthening.
24310.........  Revision of arm       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
24320.........  Repair of arm tendon  ......  T             0051     41.0893    2,525.68  ..........      505.14
24330.........  Revision of arm        CH...  T             0052       66.58    4,092.54  ..........      818.51
                 muscles.
24331.........  Revision of arm       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 muscles.
24332.........  Tenolysis, triceps..  ......  T             0049     20.8706    1,282.87  ..........      256.57
24340.........  Repair of biceps      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
24341.........  Repair arm tendon/    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 muscle.

[[Page 68298]]

 
24342.........  Repair of ruptured    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
24343.........  Repr elbow lat        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ligmnt w/tiss.
24344.........  Reconstruct elbow      CH...  T             0052       66.58    4,092.54  ..........      818.51
                 lat ligmnt.
24345.........  Repr elbw med ligmnt  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 w/tissu.
24346.........  Reconstruct elbow     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 med ligmnt.
24350.........  Repair of tennis      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24351.........  Repair of tennis      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24352.........  Repair of tennis      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24354.........  Repair of tennis      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24356.........  Revision of tennis    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 elbow.
24360.........  Reconstruct elbow     ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
24361.........  Reconstruct elbow     ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
                 joint.
24362.........  Reconstruct elbow     ......  T             0048     47.4378    2,915.91  ..........      583.18
                 joint.
24363.........  Replace elbow joint.  ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
24365.........  Reconstruct head of   ......  T             0047     33.4505    2,056.14      537.03      411.23
                 radius.
24366.........  Reconstruct head of   ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
                 radius.
24400.........  Revision of humerus.  ......  T             0050     25.1296    1,544.67  ..........      308.93
24410.........  Revision of humerus.  ......  T             0050     25.1296    1,544.67  ..........      308.93
24420.........  Revision of humerus.  ......  T             0051     41.0893    2,525.68  ..........      505.14
24430.........  Repair of humerus...   CH...  T             0052       66.58    4,092.54  ..........      818.51
24435.........  Repair humerus with    CH...  T             0052       66.58    4,092.54  ..........      818.51
                 graft.
24470.........  Revision of elbow     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
24495.........  Decompression of      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 forearm.
24498.........  Reinforce humerus...   CH...  T             0052       66.58    4,092.54  ..........      818.51
24500.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24505.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24515.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24516.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24530.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24535.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24538.........  Treat humerus          CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
24545.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24546.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24560.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24565.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24566.........  Treat humerus          CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
24575.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24576.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24577.........  Treat humerus         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24579.........  Treat humerus          CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24582.........  Treat humerus          CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
24586.........  Treat elbow fracture   CH...  T             0064     57.2172    3,517.03      835.79      703.41
24587.........  Treat elbow fracture   CH...  T             0064     57.2172    3,517.03      835.79      703.41
24600.........  Treat elbow           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
24605.........  Treat elbow           ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
24615.........  Treat elbow            CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 dislocation.
24620.........  Treat elbow fracture  ......  T             0043      1.6857      103.62  ..........       20.72
24635.........  Treat elbow fracture   CH...  T             0064     57.2172    3,517.03      835.79      703.41
24640.........  Treat elbow           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
24650.........  Treat radius          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24655.........  Treat radius          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
24665.........  Treat radius           CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
24666.........  Treat radius           CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
24670.........  Treat ulnar fracture  ......  T             0043      1.6857      103.62  ..........       20.72
24675.........  Treat ulnar fracture  ......  T             0043      1.6857      103.62  ..........       20.72
24685.........  Treat ulnar fracture   CH...  T             0063     37.5382    2,307.40      548.33      461.48
24800.........  Fusion of elbow       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
24802.........  Fusion/graft of       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 elbow joint.
24925.........  Amputation follow-up  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 surgery.
24935.........  Revision of           ......  T             0052       66.58    4,092.54  ..........      818.51
                 amputation.
24999.........  Upper arm/elbow       ......  T             0043      1.6857      103.62  ..........       20.72
                 surgery.
25000.........  Incision of tendon    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 sheath.
25001.........  Incise flexor carpi   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 radialis.
25020.........  Decompress forearm 1  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 space.
25023.........  Decompress forearm 1  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 space.
25024.........  Decompress forearm 2  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 spaces.
25025.........  Decompress forearm 2  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 spaces.
25028.........  Drainage of forearm   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
25031.........  Drainage of forearm   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
25035.........  Treat forearm bone    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.

[[Page 68299]]

 
25040.........  Explore/treat wrist   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
25065.........  Biopsy forearm soft    CH...  T             0020      6.8083      418.49      107.67       83.70
                 tissues.
25066.........  Biopsy forearm soft   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 tissues.
25075.........  Removal forearm       ......  T             0021     15.1024      928.31      219.48      185.66
                 lesion subcu.
25076.........  Removal forearm       ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion deep.
25077.........  Remove tumor,         ......  T             0022     20.0656    1,233.39      354.45      246.68
                 forearm/wrist.
25085.........  Incision of wrist     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 capsule.
25100.........  Biopsy of wrist       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 joint.
25101.........  Explore/treat wrist   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
25105.........  Remove wrist joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
25107.........  Remove wrist joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 cartilage.
25109.........  Excise tendon          NI...  T             0049     20.8706    1,282.87  ..........      256.57
                 forearm/wrist.
25110.........  Remove wrist tendon   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
25111.........  Remove wrist tendon   ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
25112.........  Reremove wrist        ......  T             0053      16.154      992.95      253.49      198.59
                 tendon lesion.
25115.........  Remove wrist/forearm  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
25116.........  Remove wrist/forearm  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
25118.........  Excise wrist tendon   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 sheath.
25119.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.
25120.........  Removal of forearm    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25125.........  Remove/graft forearm  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25126.........  Remove/graft forearm  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25130.........  Removal of wrist      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25135.........  Remove & graft wrist  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25136.........  Remove & graft wrist  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25145.........  Remove forearm bone   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
25150.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.
25151.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 radius.
25170.........  Extensive forearm      CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 surgery.
25210.........  Removal of wrist      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 bone.
25215.........  Removal of wrist      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 bones.
25230.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 radius.
25240.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.
25246.........  Injection for wrist   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
25248.........  Remove forearm        ......  T             0049     20.8706    1,282.87  ..........      256.57
                 foreign body.
25250.........  Removal of wrist      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 prosthesis.
25251.........  Removal of wrist      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 prosthesis.
25259.........  Manipulate wrist w/   ......  T             0043      1.6857      103.62  ..........       20.72
                 anesthes.
25260.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25263.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25265.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25270.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25272.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25274.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon/muscle.
25275.........  Repair forearm        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon sheath.
25280.........  Revise wrist/forearm  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
25290.........  Incise wrist/forearm  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
25295.........  Release wrist/        ......  T             0049     20.8706    1,282.87  ..........      256.57
                 forearm tendon.
25300.........  Fusion of tendons at  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 wrist.
25301.........  Fusion of tendons at  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 wrist.
25310.........  Transplant forearm    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
25312.........  Transplant forearm    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
25315.........  Revise palsy hand     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon(s).
25316.........  Revise palsy hand      CH...  T             0052       66.58    4,092.54  ..........      818.51
                 tendon(s).
25320.........  Repair/revise wrist   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
25332.........  Revise wrist joint..  ......  T             0047     33.4505    2,056.14      537.03      411.23
25335.........  Realignment of hand.  ......  T             0051     41.0893    2,525.68  ..........      505.14
25337.........  Reconstruct ulna/     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 radioulnar.
25350.........  Revision of radius..   CH...  T             0052       66.58    4,092.54  ..........      818.51
25355.........  Revision of radius..  ......  T             0051     41.0893    2,525.68  ..........      505.14
25360.........  Revision of ulna....  ......  T             0050     25.1296    1,544.67  ..........      308.93
25365.........  Revise radius & ulna  ......  T             0050     25.1296    1,544.67  ..........      308.93
25370.........  Revise radius or      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ulna.
25375.........  Revise radius & ulna  ......  T             0051     41.0893    2,525.68  ..........      505.14
25390.........  Shorten radius or     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.
25391.........  Lengthen radius or    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ulna.
25392.........  Shorten radius &      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.
25393.........  Lengthen radius &     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ulna.
25394.........  Repair carpal bone,   ......  T             0053      16.154      992.95      253.49      198.59
                 shorten.
25400.........  Repair radius or      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ulna.

[[Page 68300]]

 
25405.........  Repair/graft radius   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 or ulna.
25415.........  Repair radius & ulna  ......  T             0050     25.1296    1,544.67  ..........      308.93
25420.........  Repair/graft radius    CH...  T             0052       66.58    4,092.54  ..........      818.51
                 & ulna.
25425.........  Repair/graft radius   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 or ulna.
25426.........  Repair/graft radius   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 & ulna.
25430.........  Vasc graft into       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 carpal bone.
25431.........  Repair nonunion       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 carpal bone.
25440.........  Repair/graft wrist     CH...  T             0052       66.58    4,092.54  ..........      818.51
                 bone.
25441.........  Reconstruct wrist     ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
                 joint.
25442.........  Reconstruct wrist     ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
                 joint.
25443.........  Reconstruct wrist     ......  T             0048     47.4378    2,915.91  ..........      583.18
                 joint.
25444.........  Reconstruct wrist     ......  T             0048     47.4378    2,915.91  ..........      583.18
                 joint.
25445.........  Reconstruct wrist     ......  T             0048     47.4378    2,915.91  ..........      583.18
                 joint.
25446.........  Wrist replacement...  ......  T             0425    107.1942    6,589.01    1,378.01    1,317.80
25447.........  Repair wrist          ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint(s).
25449.........  Remove wrist joint    ......  T             0047     33.4505    2,056.14      537.03      411.23
                 implant.
25450.........  Revision of wrist     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
25455.........  Revision of wrist     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
25490.........  Reinforce radius....  ......  T             0051     41.0893    2,525.68  ..........      505.14
25491.........  Reinforce ulna......  ......  T             0051     41.0893    2,525.68  ..........      505.14
25492.........  Reinforce radius and  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ulna.
25500.........  Treat fracture of     ......  T             0043      1.6857      103.62  ..........       20.72
                 radius.
25505.........  Treat fracture of     ......  T             0043      1.6857      103.62  ..........       20.72
                 radius.
25515.........  Treat fracture of      CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 radius.
25520.........  Treat fracture of     ......  T             0043      1.6857      103.62  ..........       20.72
                 radius.
25525.........  Treat fracture of      CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 radius.
25526.........  Treat fracture of      CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 radius.
25530.........  Treat fracture of     ......  T             0043      1.6857      103.62  ..........       20.72
                 ulna.
25535.........  Treat fracture of     ......  T             0043      1.6857      103.62  ..........       20.72
                 ulna.
25545.........  Treat fracture of      CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 ulna.
25560.........  Treat fracture        ......  T             0043      1.6857      103.62  ..........       20.72
                 radius & ulna.
25565.........  Treat fracture        ......  T             0043      1.6857      103.62  ..........       20.72
                 radius & ulna.
25574.........  Treat fracture         CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 radius & ulna.
25575.........  Treat fracture         CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 radius/ulna.
25600.........  Treat fracture        ......  T             0043      1.6857      103.62  ..........       20.72
                 radius/ulna.
25605.........  Treat fracture        ......  T             0043      1.6857      103.62  ..........       20.72
                 radius/ulna.
25606.........  Treat fx distal        NI...  T             0062     25.5264    1,569.06      372.87      313.81
                 radial.
25607.........  Treat fx rad extra-    NI...  T             0064     57.2172    3,517.03      835.79      703.41
                 articul.
25608.........  Treat fx rad intra-    NI...  T             0064     57.2172    3,517.03      835.79      703.41
                 articul.
25609.........  Treat fx radial 3+     NI...  T             0064     57.2172    3,517.03      835.79      703.41
                 frag.
25611.........  Treat fracture         CH...  D       ..........  ..........  ..........  ..........  ..........
                 radius/ulna.
25620.........  Treat fracture         CH...  D       ..........  ..........  ..........  ..........  ..........
                 radius/ulna.
25622.........  Treat wrist bone      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
25624.........  Treat wrist bone      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
25628.........  Treat wrist bone       CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
25630.........  Treat wrist bone      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
25635.........  Treat wrist bone      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
25645.........  Treat wrist bone       CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
25650.........  Treat wrist bone      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
25651.........  Pin ulnar styloid      CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
25652.........  Treat fracture ulnar   CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 styloid.
25660.........  Treat wrist           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
25670.........  Treat wrist            CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
25671.........  Pin radioulnar         CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
25675.........  Treat wrist           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
25676.........  Treat wrist            CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
25680.........  Treat wrist fracture  ......  T             0043      1.6857      103.62  ..........       20.72
25685.........  Treat wrist fracture   CH...  T             0062     25.5264    1,569.06      372.87      313.81
25690.........  Treat wrist           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
25695.........  Treat wrist            CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
25800.........  Fusion of wrist        CH...  T             0052       66.58    4,092.54  ..........      818.51
                 joint.
25805.........  Fusion/graft of       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 wrist joint.
25810.........  Fusion/graft of        CH...  T             0052       66.58    4,092.54  ..........      818.51
                 wrist joint.
25820.........  Fusion of hand bones  ......  T             0053      16.154      992.95      253.49      198.59
25825.........  Fuse hand bones with  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 graft.
25830.........  Fusion, radioulnar     CH...  T             0052       66.58    4,092.54  ..........      818.51
                 jnt/ulna.
25907.........  Amputation follow-up  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 surgery.
25922.........  Amputate hand at      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 wrist.
25929.........  Amputation follow-up  ......  T             0686     14.0346      862.68  ..........      172.54
                 surgery.
25999.........  Forearm or wrist      ......  T             0043      1.6857      103.62  ..........       20.72
                 surgery.

[[Page 68301]]

 
26010.........  Drainage of finger    ......  T             0006      1.4392       88.46  ..........       17.69
                 abscess.
26011.........  Drainage of finger    ......  T             0007     11.1535      685.58  ..........      137.12
                 abscess.
26020.........  Drain hand tendon     ......  T             0053      16.154      992.95      253.49      198.59
                 sheath.
26025.........  Drainage of palm      ......  T             0053      16.154      992.95      253.49      198.59
                 bursa.
26030.........  Drainage of palm      ......  T             0053      16.154      992.95      253.49      198.59
                 bursa(s).
26034.........  Treat hand bone       ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
26035.........  Decompress fingers/   ......  T             0053      16.154      992.95      253.49      198.59
                 hand.
26037.........  Decompress fingers/   ......  T             0053      16.154      992.95      253.49      198.59
                 hand.
26040.........  Release palm          ......  T             0054     25.8758    1,590.53  ..........      318.11
                 contracture.
26045.........  Release palm          ......  T             0054     25.8758    1,590.53  ..........      318.11
                 contracture.
26055.........  Incise finger tendon  ......  T             0053      16.154      992.95      253.49      198.59
                 sheath.
26060.........  Incision of finger    ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26070.........  Explore/treat hand    ......  T             0053      16.154      992.95      253.49      198.59
                 joint.
26075.........  Explore/treat finger  ......  T             0053      16.154      992.95      253.49      198.59
                 joint.
26080.........  Explore/treat finger  ......  T             0053      16.154      992.95      253.49      198.59
                 joint.
26100.........  Biopsy hand joint     ......  T             0053      16.154      992.95      253.49      198.59
                 lining.
26105.........  Biopsy finger joint   ......  T             0053      16.154      992.95      253.49      198.59
                 lining.
26110.........  Biopsy finger joint   ......  T             0053      16.154      992.95      253.49      198.59
                 lining.
26115.........  Removal hand lesion   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 subcut.
26116.........  Removal hand lesion,  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 deep.
26117.........  Remove tumor, hand/   ......  T             0022     20.0656    1,233.39      354.45      246.68
                 finger.
26121.........  Release palm          ......  T             0054     25.8758    1,590.53  ..........      318.11
                 contracture.
26123.........  Release palm          ......  T             0054     25.8758    1,590.53  ..........      318.11
                 contracture.
26125.........  Release palm          ......  T             0053      16.154      992.95      253.49      198.59
                 contracture.
26130.........  Remove wrist joint    ......  T             0053      16.154      992.95      253.49      198.59
                 lining.
26135.........  Revise finger joint,  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 each.
26140.........  Revise finger joint,  ......  T             0053      16.154      992.95      253.49      198.59
                 each.
26145.........  Tendon excision,      ......  T             0053      16.154      992.95      253.49      198.59
                 palm/finger.
26160.........  Remove tendon sheath  ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
26170.........  Removal of palm       ......  T             0053      16.154      992.95      253.49      198.59
                 tendon, each.
26180.........  Removal of finger     ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26185.........  Remove finger bone..  ......  T             0053      16.154      992.95      253.49      198.59
26200.........  Remove hand bone      ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
26205.........  Remove/graft bone     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 lesion.
26210.........  Removal of finger     ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
26215.........  Remove/graft finger   ......  T             0053      16.154      992.95      253.49      198.59
                 lesion.
26230.........  Partial removal of    ......  T             0053      16.154      992.95      253.49      198.59
                 hand bone.
26235.........  Partial removal,      ......  T             0053      16.154      992.95      253.49      198.59
                 finger bone.
26236.........  Partial removal,      ......  T             0053      16.154      992.95      253.49      198.59
                 finger bone.
26250.........  Extensive hand        ......  T             0053      16.154      992.95      253.49      198.59
                 surgery.
26255.........  Extensive hand        ......  T             0054     25.8758    1,590.53  ..........      318.11
                 surgery.
26260.........  Extensive finger      ......  T             0053      16.154      992.95      253.49      198.59
                 surgery.
26261.........  Extensive finger      ......  T             0053      16.154      992.95      253.49      198.59
                 surgery.
26262.........  Partial removal of    ......  T             0053      16.154      992.95      253.49      198.59
                 finger.
26320.........  Removal of implant    ......  T             0021     15.1024      928.31      219.48      185.66
                 from hand.
26340.........  Manipulate finger w/  ......  T             0043      1.6857      103.62  ..........       20.72
                 anesth.
26350.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26352.........  Repair/graft hand     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26356.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26357.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26358.........  Repair/graft hand     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26370.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26372.........  Repair/graft hand     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26373.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26390.........  Revise hand/finger    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26392.........  Repair/graft hand     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26410.........  Repair hand tendon..  ......  T             0053      16.154      992.95      253.49      198.59
26412.........  Repair/graft hand     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26415.........  Excision, hand/       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 finger tendon.
26416.........  Graft hand or finger  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26418.........  Repair finger tendon  ......  T             0053      16.154      992.95      253.49      198.59
26420.........  Repair/graft finger   ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26426.........  Repair finger/hand    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26428.........  Repair/graft finger   ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26432.........  Repair finger tendon  ......  T             0053      16.154      992.95      253.49      198.59
26433.........  Repair finger tendon  ......  T             0053      16.154      992.95      253.49      198.59
26434.........  Repair/graft finger   ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26437.........  Realignment of        ......  T             0053      16.154      992.95      253.49      198.59
                 tendons.
26440.........  Release palm/finger   ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26442.........  Release palm &        ......  T             0054     25.8758    1,590.53  ..........      318.11
                 finger tendon.

[[Page 68302]]

 
26445.........  Release hand/finger   ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26449.........  Release forearm/hand  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26450.........  Incision of palm      ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26455.........  Incision of finger    ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26460.........  Incise hand/finger    ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26471.........  Fusion of finger      ......  T             0053      16.154      992.95      253.49      198.59
                 tendons.
26474.........  Fusion of finger      ......  T             0053      16.154      992.95      253.49      198.59
                 tendons.
26476.........  Tendon lengthening..  ......  T             0053      16.154      992.95      253.49      198.59
26477.........  Tendon shortening...  ......  T             0053      16.154      992.95      253.49      198.59
26478.........  Lengthening of hand   ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26479.........  Shortening of hand    ......  T             0053      16.154      992.95      253.49      198.59
                 tendon.
26480.........  Transplant hand       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26483.........  Transplant/graft      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 hand tendon.
26485.........  Transplant palm       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 tendon.
26489.........  Transplant/graft      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 palm tendon.
26490.........  Revise thumb tendon.  ......  T             0054     25.8758    1,590.53  ..........      318.11
26492.........  Tendon transfer with  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 graft.
26494.........  Hand tendon/muscle    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 transfer.
26496.........  Revise thumb tendon.  ......  T             0054     25.8758    1,590.53  ..........      318.11
26497.........  Finger tendon         ......  T             0054     25.8758    1,590.53  ..........      318.11
                 transfer.
26498.........  Finger tendon         ......  T             0054     25.8758    1,590.53  ..........      318.11
                 transfer.
26499.........  Revision of finger..  ......  T             0054     25.8758    1,590.53  ..........      318.11
26500.........  Hand tendon           ......  T             0053      16.154      992.95      253.49      198.59
                 reconstruction.
26502.........  Hand tendon           ......  T             0054     25.8758    1,590.53  ..........      318.11
                 reconstruction.
26504.........  Hand tendon            CH...  D       ..........  ..........  ..........  ..........  ..........
                 reconstruction.
26508.........  Release thumb         ......  T             0053      16.154      992.95      253.49      198.59
                 contracture.
26510.........  Thumb tendon          ......  T             0054     25.8758    1,590.53  ..........      318.11
                 transfer.
26516.........  Fusion of knuckle     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26517.........  Fusion of knuckle     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joints.
26518.........  Fusion of knuckle     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joints.
26520.........  Release knuckle       ......  T             0053      16.154      992.95      253.49      198.59
                 contracture.
26525.........  Release finger        ......  T             0053      16.154      992.95      253.49      198.59
                 contracture.
26530.........  Revise knuckle joint  ......  T             0047     33.4505    2,056.14      537.03      411.23
26531.........  Revise knuckle with   ......  T             0048     47.4378    2,915.91  ..........      583.18
                 implant.
26535.........  Revise finger joint.  ......  T             0047     33.4505    2,056.14      537.03      411.23
26536.........  Revise/implant        ......  T             0048     47.4378    2,915.91  ..........      583.18
                 finger joint.
26540.........  Repair hand joint...  ......  T             0053      16.154      992.95      253.49      198.59
26541.........  Repair hand joint     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 with graft.
26542.........  Repair hand joint     ......  T             0053      16.154      992.95      253.49      198.59
                 with graft.
26545.........  Reconstruct finger    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26546.........  Repair nonunion hand  ......  T             0054     25.8758    1,590.53  ..........      318.11
26548.........  Reconstruct finger    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26550.........  Construct thumb       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 replacement.
26555.........  Positional change of  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 finger.
26560.........  Repair of web finger  ......  T             0053      16.154      992.95      253.49      198.59
26561.........  Repair of web finger  ......  T             0054     25.8758    1,590.53  ..........      318.11
26562.........  Repair of web finger  ......  T             0054     25.8758    1,590.53  ..........      318.11
26565.........  Correct metacarpal    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 flaw.
26567.........  Correct finger        ......  T             0054     25.8758    1,590.53  ..........      318.11
                 deformity.
26568.........  Lengthen metacarpal/  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 finger.
26580.........  Repair hand           ......  T             0053      16.154      992.95      253.49      198.59
                 deformity.
26587.........  Reconstruct extra     ......  T             0053      16.154      992.95      253.49      198.59
                 finger.
26590.........  Repair finger         ......  T             0053      16.154      992.95      253.49      198.59
                 deformity.
26591.........  Repair muscles of     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 hand.
26593.........  Release muscles of    ......  T             0053      16.154      992.95      253.49      198.59
                 hand.
26596.........  Excision              ......  T             0053      16.154      992.95      253.49      198.59
                 constricting tissue.
26600.........  Treat metacarpal      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
26605.........  Treat metacarpal      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
26607.........  Treat metacarpal      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
26608.........  Treat metacarpal       CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
26615.........  Treat metacarpal       CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
26641.........  Treat thumb           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26645.........  Treat thumb fracture  ......  T             0043      1.6857      103.62  ..........       20.72
26650.........  Treat thumb fracture   CH...  T             0062     25.5264    1,569.06      372.87      313.81
26665.........  Treat thumb fracture   CH...  T             0063     37.5382    2,307.40      548.33      461.48
26670.........  Treat hand            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26675.........  Treat hand            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26676.........  Pin hand dislocation   CH...  T             0062     25.5264    1,569.06      372.87      313.81
26685.........  Treat hand             CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
26686.........  Treat hand             CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 dislocation.

[[Page 68303]]

 
26700.........  Treat knuckle         ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26705.........  Treat knuckle         ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26706.........  Pin knuckle           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26715.........  Treat knuckle          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
26720.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26725.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26727.........  Treat finger           CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture, each.
26735.........  Treat finger           CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture, each.
26740.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26742.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26746.........  Treat finger           CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture, each.
26750.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26755.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
26756.........  Pin finger fracture,   CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 each.
26765.........  Treat finger           CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture, each.
26770.........  Treat finger          ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
26775.........  Treat finger          ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
26776.........  Pin finger             CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
26785.........  Treat finger           CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
26820.........  Thumb fusion with     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 graft.
26841.........  Fusion of thumb.....  ......  T             0054     25.8758    1,590.53  ..........      318.11
26842.........  Thumb fusion with     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 graft.
26843.........  Fusion of hand joint  ......  T             0054     25.8758    1,590.53  ..........      318.11
26844.........  Fusion/graft of hand  ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26850.........  Fusion of knuckle...  ......  T             0054     25.8758    1,590.53  ..........      318.11
26852.........  Fusion of knuckle     ......  T             0054     25.8758    1,590.53  ..........      318.11
                 with graft.
26860.........  Fusion of finger      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26861.........  Fusion of finger      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 jnt, add-on.
26862.........  Fusion/graft of       ......  T             0054     25.8758    1,590.53  ..........      318.11
                 finger joint.
26863.........  Fuse/graft added      ......  T             0054     25.8758    1,590.53  ..........      318.11
                 joint.
26910.........  Amputate metacarpal   ......  T             0054     25.8758    1,590.53  ..........      318.11
                 bone.
26951.........  Amputation of finger/ ......  T             0053      16.154      992.95      253.49      198.59
                 thumb.
26952.........  Amputation of finger/ ......  T             0053      16.154      992.95      253.49      198.59
                 thumb.
26989.........  Hand/finger surgery.  ......  T             0043      1.6857      103.62  ..........       20.72
26990.........  Drainage of pelvis    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
26991.........  Drainage of pelvis    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
27000.........  Incision of hip       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27001.........  Incision of hip       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27003.........  Incision of hip       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27033.........  Exploration of hip    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
27035.........  Denervation of hip     CH...  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
27040.........  Biopsy of soft        ......  T             0020      6.8083      418.49      107.67       83.70
                 tissues.
27041.........  Biopsy of soft        ......  T             0020      6.8083      418.49      107.67       83.70
                 tissues.
27047.........  Remove hip/pelvis     ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
27048.........  Remove hip/pelvis     ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
27049.........  Remove tumor, hip/    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 pelvis.
27050.........  Biopsy of sacroiliac  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 joint.
27052.........  Biopsy of hip joint.  ......  T             0049     20.8706    1,282.87  ..........      256.57
27060.........  Removal of ischial    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
27062.........  Remove femur lesion/  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
27065.........  Removal of hip bone   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
27066.........  Removal of hip bone   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lesion.
27067.........  Remove/graft hip      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 bone lesion.
27080.........  Removal of tail bone  ......  T             0050     25.1296    1,544.67  ..........      308.93
27086.........  Remove hip foreign    ......  T             0020      6.8083      418.49      107.67       83.70
                 body.
27087.........  Remove hip foreign    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 body.
27093.........  Injection for hip x-  ......  N       ..........  ..........  ..........  ..........  ..........
                 ray.
27095.........  Injection for hip x-  ......  N       ..........  ..........  ..........  ..........  ..........
                 ray.
27097.........  Revision of hip       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27098.........  Transfer tendon to    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 pelvis.
27100.........  Transfer of           ......  T             0051     41.0893    2,525.68  ..........      505.14
                 abdominal muscle.
27105.........  Transfer of spinal    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 muscle.
27110.........  Transfer of           ......  T             0051     41.0893    2,525.68  ..........      505.14
                 iliopsoas muscle.
27111.........  Transfer of           ......  T             0051     41.0893    2,525.68  ..........      505.14
                 iliopsoas muscle.
27193.........  Treat pelvic ring     ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27194.........  Treat pelvic ring     ......  T             0045     14.5947      897.11      268.47      179.42
                 fracture.
27200.........  Treat tail bone       ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27202.........  Treat tail bone        CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27216.........  Treat pelvic ring     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 fracture.
27220.........  Treat hip socket      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.

[[Page 68304]]

 
27230.........  Treat thigh fracture  ......  T             0043      1.6857      103.62  ..........       20.72
27235.........  Treat thigh fracture  ......  T             0050     25.1296    1,544.67  ..........      308.93
27238.........  Treat thigh fracture  ......  T             0043      1.6857      103.62  ..........       20.72
27246.........  Treat thigh fracture  ......  T             0043      1.6857      103.62  ..........       20.72
27250.........  Treat hip             ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27252.........  Treat hip             ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27256.........  Treat hip             ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27257.........  Treat hip             ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27265.........  Treat hip             ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27266.........  Treat hip             ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27275.........  Manipulation of hip   ......  T             0045     14.5947      897.11      268.47      179.42
                 joint.
27299.........  Pelvis/hip joint      ......  T             0043      1.6857      103.62  ..........       20.72
                 surgery.
27301.........  Drain thigh/knee      ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
27305.........  Incise thigh tendon   ......  T             0049     20.8706    1,282.87  ..........      256.57
                 & fascia.
27306.........  Incision of thigh     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27307.........  Incision of thigh     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendons.
27310.........  Exploration of knee   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
27315.........  Partial removal,       CH...  D       ..........  ..........  ..........  ..........  ..........
                 thigh nerve.
27320.........  Partial removal,       CH...  D       ..........  ..........  ..........  ..........  ..........
                 thigh nerve.
27323.........  Biopsy, thigh soft     CH...  T             0020      6.8083      418.49      107.67       83.70
                 tissues.
27324.........  Biopsy, thigh soft    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 tissues.
27325.........  Neurectomy,            NI...  T             0220     17.8499    1,097.20  ..........      219.44
                 hamstring.
27326.........  Neurectomy,            NI...  T             0220     17.8499    1,097.20  ..........      219.44
                 popliteal.
27327.........  Removal of thigh      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
27328.........  Removal of thigh      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
27329.........  Remove tumor, thigh/  ......  T             0022     20.0656    1,233.39      354.45      246.68
                 knee.
27330.........  Biopsy, knee joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
27331.........  Explore/treat knee    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
27332.........  Removal of knee       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 cartilage.
27333.........  Removal of knee       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 cartilage.
27334.........  Remove knee joint     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
27335.........  Remove knee joint     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
27340.........  Removal of kneecap    ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
27345.........  Removal of knee cyst  ......  T             0049     20.8706    1,282.87  ..........      256.57
27347.........  Remove knee cyst....  ......  T             0049     20.8706    1,282.87  ..........      256.57
27350.........  Removal of kneecap..  ......  T             0050     25.1296    1,544.67  ..........      308.93
27355.........  Remove femur lesion.  ......  T             0050     25.1296    1,544.67  ..........      308.93
27356.........  Remove femur lesion/  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 graft.
27357.........  Remove femur lesion/  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 graft.
27358.........  Remove femur lesion/  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 fixation.
27360.........  Partial removal, leg  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 bone(s).
27370.........  Injection for knee x- ......  N       ..........  ..........  ..........  ..........  ..........
                 ray.
27372.........  Removal of foreign    ......  T             0022     20.0656    1,233.39      354.45      246.68
                 body.
27380.........  Repair of kneecap     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27381.........  Repair/graft kneecap  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27385.........  Repair of thigh       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 muscle.
27386.........  Repair/graft of       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 thigh muscle.
27390.........  Incision of thigh     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27391.........  Incision of thigh     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendons.
27392.........  Incision of thigh     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendons.
27393.........  Lengthening of thigh  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27394.........  Lengthening of thigh  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendons.
27395.........  Lengthening of thigh  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendons.
27396.........  Transplant of thigh   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27397.........  Transplants of thigh  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendons.
27400.........  Revise thigh muscles/ ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendons.
27403.........  Repair of knee        ......  T             0050     25.1296    1,544.67  ..........      308.93
                 cartilage.
27405.........  Repair of knee        ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ligament.
27407.........  Repair of knee         CH...  T             0052       66.58    4,092.54  ..........      818.51
                 ligament.
27409.........  Repair of knee        ......  T             0051     41.0893    2,525.68  ..........      505.14
                 ligaments.
27412.........  Autochondrocyte       ......  T             0042     45.5027    2,796.96      804.74      559.39
                 implant knee.
27415.........  Osteochondral knee    ......  T             0042     45.5027    2,796.96      804.74      559.39
                 allograft.
27418.........  Repair degenerated    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 kneecap.
27420.........  Revision of unstable  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 kneecap.
27422.........  Revision of unstable  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 kneecap.
27424.........  Revision/removal of   ......  T             0051     41.0893    2,525.68  ..........      505.14
                 kneecap.
27425.........  Lat retinacular       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 release open.
27427.........  Reconstruction, knee   CH...  T             0051     41.0893    2,525.68  ..........      505.14
27428.........  Reconstruction, knee  ......  T             0052       66.58    4,092.54  ..........      818.51
27429.........  Reconstruction, knee  ......  T             0052       66.58    4,092.54  ..........      818.51

[[Page 68305]]

 
27430.........  Revision of thigh     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 muscles.
27435.........  Incision of knee      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 joint.
27437.........  Revise kneecap......  ......  T             0047     33.4505    2,056.14      537.03      411.23
27438.........  Revise kneecap with   ......  T             0048     47.4378    2,915.91  ..........      583.18
                 implant.
27440.........  Revision of knee      ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
27441.........  Revision of knee      ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
27442.........  Revision of knee      ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
27443.........  Revision of knee      ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
27446.........  Revision of knee      ......  T             0681    205.6815   12,642.83  ..........    2,528.57
                 joint.
27475.........  Surgery to stop leg   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 growth.
27496.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 thigh/knee.
27497.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 thigh/knee.
27498.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 thigh/knee.
27499.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 thigh/knee.
27500.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27501.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27502.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27503.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27508.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27509.........  Treatment of thigh     CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
27510.........  Treatment of thigh    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27516.........  Treat thigh fx        ......  T             0043      1.6857      103.62  ..........       20.72
                 growth plate.
27517.........  Treat thigh fx        ......  T             0043      1.6857      103.62  ..........       20.72
                 growth plate.
27520.........  Treat kneecap         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27524.........  Treat kneecap          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27530.........  Treat knee fracture.  ......  T             0043      1.6857      103.62  ..........       20.72
27532.........  Treat knee fracture.  ......  T             0043      1.6857      103.62  ..........       20.72
27538.........  Treat knee            ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture(s).
27550.........  Treat knee            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27552.........  Treat knee            ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27560.........  Treat kneecap         ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27562.........  Treat kneecap         ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27566.........  Treat kneecap          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
27570.........  Fixation of knee      ......  T             0045     14.5947      897.11      268.47      179.42
                 joint.
27594.........  Amputation follow-up  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 surgery.
27599.........  Leg surgery           ......  T             0043      1.6857      103.62  ..........       20.72
                 procedure.
27600.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lower leg.
27601.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lower leg.
27602.........  Decompression of      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lower leg.
27603.........  Drain lower leg       ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
27604.........  Drain lower leg       ......  T             0049     20.8706    1,282.87  ..........      256.57
                 bursa.
27605.........  Incision of achilles  ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
27606.........  Incision of achilles  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon.
27607.........  Treat lower leg bone  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
27610.........  Explore/treat ankle   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
27612.........  Exploration of ankle  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
27613.........  Biopsy lower leg      ......  T             0020      6.8083      418.49      107.67       83.70
                 soft tissue.
27614.........  Biopsy lower leg      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 soft tissue.
27615.........  Remove tumor, lower    CH...  T             0050     25.1296    1,544.67  ..........      308.93
                 leg.
27618.........  Remove lower leg      ......  T             0021     15.1024      928.31      219.48      185.66
                 lesion.
27619.........  Remove lower leg      ......  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
27620.........  Explore/treat ankle   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 joint.
27625.........  Remove ankle joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
27626.........  Remove ankle joint    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 lining.
27630.........  Removal of tendon     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 lesion.
27635.........  Remove lower leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 bone lesion.
27637.........  Remove/graft leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 bone lesion.
27638.........  Remove/graft leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 bone lesion.
27640.........  Partial removal of    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tibia.
27641.........  Partial removal of    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 fibula.
27647.........  Extensive ankle/heel  ......  T             0051     41.0893    2,525.68  ..........      505.14
                 surgery.
27648.........  Injection for ankle   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
27650.........  Repair achilles       ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
27652.........  Repair/graft           CH...  T             0052       66.58    4,092.54  ..........      818.51
                 achilles tendon.
27654.........  Repair of achilles    ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
27656.........  Repair leg fascia     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 defect.
27658.........  Repair of leg         ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon, each.
27659.........  Repair of leg         ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon, each.
27664.........  Repair of leg         ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendon, each.
27665.........  Repair of leg         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon, each.

[[Page 68306]]

 
27675.........  Repair lower leg      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 tendons.
27676.........  Repair lower leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendons.
27680.........  Release of lower leg  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27681.........  Release of lower leg  ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendons.
27685.........  Revision of lower     ......  T             0050     25.1296    1,544.67  ..........      308.93
                 leg tendon.
27686.........  Revise lower leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendons.
27687.........  Revision of calf      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 tendon.
27690.........  Revise lower leg      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
27691.........  Revise lower leg      ......  T             0051     41.0893    2,525.68  ..........      505.14
                 tendon.
27692.........  Revise additional     ......  T             0051     41.0893    2,525.68  ..........      505.14
                 leg tendon.
27695.........  Repair of ankle       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ligament.
27696.........  Repair of ankle       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ligaments.
27698.........  Repair of ankle       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 ligament.
27700.........  Revision of ankle     ......  T             0047     33.4505    2,056.14      537.03      411.23
                 joint.
27704.........  Removal of ankle      ......  T             0049     20.8706    1,282.87  ..........      256.57
                 implant.
27705.........  Incision of tibia...  ......  T             0051     41.0893    2,525.68  ..........      505.14
27707.........  Incision of fibula..  ......  T             0049     20.8706    1,282.87  ..........      256.57
27709.........  Incision of tibia &   ......  T             0050     25.1296    1,544.67  ..........      308.93
                 fibula.
27730.........  Repair of tibia       ......  T             0050     25.1296    1,544.67  ..........      308.93
                 epiphysis.
27732.........  Repair of fibula      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 epiphysis.
27734.........  Repair lower leg      ......  T             0050     25.1296    1,544.67  ..........      308.93
                 epiphyses.
27740.........  Repair of leg         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 epiphyses.
27742.........  Repair of leg         ......  T             0051     41.0893    2,525.68  ..........      505.14
                 epiphyses.
27745.........  Reinforce tibia.....   CH...  T             0052       66.58    4,092.54  ..........      818.51
27750.........  Treatment of tibia    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27752.........  Treatment of tibia    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27756.........  Treatment of tibia     CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
27758.........  Treatment of tibia     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27759.........  Treatment of tibia     CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
27760.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27762.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27766.........  Treatment of ankle     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27780.........  Treatment of fibula   ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27781.........  Treatment of fibula   ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27784.........  Treatment of fibula    CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27786.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27788.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27792.........  Treatment of ankle     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27808.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27810.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27814.........  Treatment of ankle     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27816.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27818.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27822.........  Treatment of ankle     CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27823.........  Treatment of ankle     CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
27824.........  Treat lower leg       ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27825.........  Treat lower leg       ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
27826.........  Treat lower leg        CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
27827.........  Treat lower leg        CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
27828.........  Treat lower leg        CH...  T             0064     57.2172    3,517.03      835.79      703.41
                 fracture.
27829.........  Treat lower leg        CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 joint.
27830.........  Treat lower leg       ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27831.........  Treat lower leg       ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27832.........  Treat lower leg        CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
27840.........  Treat ankle           ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
27842.........  Treat ankle           ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
27846.........  Treat ankle            CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
27848.........  Treat ankle            CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
27860.........  Fixation of ankle     ......  T             0045     14.5947      897.11      268.47      179.42
                 joint.
27870.........  Fusion of ankle        CH...  T             0052       66.58    4,092.54  ..........      818.51
                 joint, open.
27871.........  Fusion of              CH...  T             0052       66.58    4,092.54  ..........      818.51
                 tibiofibular joint.
27884.........  Amputation follow-up  ......  T             0049     20.8706    1,282.87  ..........      256.57
                 surgery.
27889.........  Amputation of foot    ......  T             0050     25.1296    1,544.67  ..........      308.93
                 at ankle.
27892.........  Decompression of leg  ......  T             0049     20.8706    1,282.87  ..........      256.57
27893.........  Decompression of leg  ......  T             0049     20.8706    1,282.87  ..........      256.57
27894.........  Decompression of leg  ......  T             0049     20.8706    1,282.87  ..........      256.57
27899.........  Leg/ankle surgery     ......  T             0043      1.6857      103.62  ..........       20.72
                 procedure.
28001.........  Drainage of bursa of  ......  T             0007     11.1535      685.58  ..........      137.12
                 foot.
28002.........  Treatment of foot     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 infection.
28003.........  Treatment of foot     ......  T             0049     20.8706    1,282.87  ..........      256.57
                 infection.

[[Page 68307]]

 
28005.........  Treat foot bone       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesion.
28008.........  Incision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 fascia.
28010.........  Incision of toe       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28011.........  Incision of toe       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendons.
28020.........  Exploration of foot   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint.
28022.........  Exploration of foot   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint.
28024.........  Exploration of toe    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint.
28030.........  Removal of foot        CH...  D       ..........  ..........  ..........  ..........  ..........
                 nerve.
28035.........  Decompression of      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 tibia nerve.
28043.........  Excision of foot       CH...  T             0022     20.0656    1,233.39      354.45      246.68
                 lesion.
28045.........  Excision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesion.
28046.........  Resection of tumor,   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 foot.
28050.........  Biopsy of foot joint  ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lining.
28052.........  Biopsy of foot joint  ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lining.
28054.........  Biopsy of toe joint   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lining.
28055.........  Neurectomy, foot....   NI...  T             0220     17.8499    1,097.20  ..........      219.44
28060.........  Partial removal,      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 foot fascia.
28062.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 fascia.
28070.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint lining.
28072.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint lining.
28080.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesion.
28086.........  Excise foot tendon    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 sheath.
28088.........  Excise foot tendon    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 sheath.
28090.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesion.
28092.........  Removal of toe        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesions.
28100.........  Removal of ankle/     ......  T             0055     20.4263    1,255.56      355.34      251.11
                 heel lesion.
28102.........  Remove/graft foot     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 lesion.
28103.........  Remove/graft foot     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 lesion.
28104.........  Removal of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesion.
28106.........  Remove/graft foot     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 lesion.
28107.........  Remove/graft foot     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 lesion.
28108.........  Removal of toe        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 lesions.
28110.........  Part removal of       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28111.........  Part removal of       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28112.........  Part removal of       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28113.........  Part removal of       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28114.........  Removal of            ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal heads.
28116.........  Revision of foot....  ......  T             0055     20.4263    1,255.56      355.34      251.11
28118.........  Removal of heel bone  ......  T             0055     20.4263    1,255.56      355.34      251.11
28119.........  Removal of heel spur  ......  T             0055     20.4263    1,255.56      355.34      251.11
28120.........  Part removal of       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 ankle/heel.
28122.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 foot bone.
28124.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 toe.
28126.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 toe.
28130.........  Removal of ankle      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 bone.
28140.........  Removal of            ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28150.........  Removal of toe......  ......  T             0055     20.4263    1,255.56      355.34      251.11
28153.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 toe.
28160.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 toe.
28171.........  Extensive foot        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 surgery.
28173.........  Extensive foot        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 surgery.
28175.........  Extensive foot        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 surgery.
28190.........  Removal of foot       ......  T             0019      4.0919      251.52       71.87       50.30
                 foreign body.
28192.........  Removal of foot       ......  T             0021     15.1024      928.31      219.48      185.66
                 foreign body.
28193.........  Removal of foot       ......  T             0020      6.8083      418.49      107.67       83.70
                 foreign body.
28200.........  Repair of foot        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28202.........  Repair/graft of foot  ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28208.........  Repair of foot        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28210.........  Repair/graft of foot  ......  T             0056     40.8559    2,511.33  ..........      502.27
                 tendon.
28220.........  Release of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28222.........  Release of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendons.
28225.........  Release of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28226.........  Release of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendons.
28230.........  Incision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon(s).
28232.........  Incision of toe       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28234.........  Incision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28238.........  Revision of foot      ......  T             0056     40.8559    2,511.33  ..........      502.27
                 tendon.
28240.........  Release of big toe..  ......  T             0055     20.4263    1,255.56      355.34      251.11
28250.........  Revision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 fascia.
28260.........  Release of midfoot    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint.

[[Page 68308]]

 
28261.........  Revision of foot      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tendon.
28262.........  Revision of foot and  ......  T             0055     20.4263    1,255.56      355.34      251.11
                 ankle.
28264.........  Release of midfoot    ......  T             0056     40.8559    2,511.33  ..........      502.27
                 joint.
28270.........  Release of foot       ......  T             0055     20.4263    1,255.56      355.34      251.11
                 contracture.
28272.........  Release of toe        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint, each.
28280.........  Fusion of toes......  ......  T             0055     20.4263    1,255.56      355.34      251.11
28285.........  Repair of hammertoe.  ......  T             0055     20.4263    1,255.56      355.34      251.11
28286.........  Repair of hammertoe.  ......  T             0055     20.4263    1,255.56      355.34      251.11
28288.........  Partial removal of    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 foot bone.
28289.........  Repair hallux         ......  T             0055     20.4263    1,255.56      355.34      251.11
                 rigidus.
28290.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28292.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28293.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28294.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28296.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28297.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28298.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28299.........  Correction of bunion  ......  T             0057     28.2349    1,735.54      475.91      347.11
28300.........  Incision of heel      ......  T             0056     40.8559    2,511.33  ..........      502.27
                 bone.
28302.........  Incision of ankle     ......  T             0055     20.4263    1,255.56      355.34      251.11
                 bone.
28304.........  Incision of midfoot   ......  T             0056     40.8559    2,511.33  ..........      502.27
                 bones.
28305.........  Incise/graft midfoot  ......  T             0056     40.8559    2,511.33  ..........      502.27
                 bones.
28306.........  Incision of           ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28307.........  Incision of           ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28308.........  Incision of           ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28309.........  Incision of           ......  T             0056     40.8559    2,511.33  ..........      502.27
                 metatarsals.
28310.........  Revision of big toe.  ......  T             0055     20.4263    1,255.56      355.34      251.11
28312.........  Revision of toe.....  ......  T             0055     20.4263    1,255.56      355.34      251.11
28313.........  Repair deformity of   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 toe.
28315.........  Removal of sesamoid   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 bone.
28320.........  Repair of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28322.........  Repair of             ......  T             0056     40.8559    2,511.33  ..........      502.27
                 metatarsals.
28340.........  Resect enlarged toe   ......  T             0055     20.4263    1,255.56      355.34      251.11
                 tissue.
28341.........  Resect enlarged toe.  ......  T             0055     20.4263    1,255.56      355.34      251.11
28344.........  Repair extra toe(s).  ......  T             0055     20.4263    1,255.56      355.34      251.11
28345.........  Repair webbed toe(s)  ......  T             0055     20.4263    1,255.56      355.34      251.11
28360.........  Reconstruct cleft     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 foot.
28400.........  Treatment of heel     ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28405.........  Treatment of heel     ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28406.........  Treatment of heel      CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
28415.........  Treat heel fracture.   CH...  T             0063     37.5382    2,307.40      548.33      461.48
28420.........  Treat/graft heel       CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
28430.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28435.........  Treatment of ankle    ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28436.........  Treatment of ankle     CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
28445.........  Treat ankle fracture   CH...  T             0063     37.5382    2,307.40      548.33      461.48
28450.........  Treat midfoot         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
28455.........  Treat midfoot         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture, each.
28456.........  Treat midfoot          CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
28465.........  Treat midfoot          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture, each.
28470.........  Treat metatarsal      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28475.........  Treat metatarsal      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28476.........  Treat metatarsal       CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
28485.........  Treat metatarsal       CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
28490.........  Treat big toe         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28495.........  Treat big toe         ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28496.........  Treat big toe          CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 fracture.
28505.........  Treat big toe          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
28510.........  Treatment of toe      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28515.........  Treatment of toe      ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28525.........  Treat toe fracture..   CH...  T             0063     37.5382    2,307.40      548.33      461.48
28530.........  Treat sesamoid bone   ......  T             0043      1.6857      103.62  ..........       20.72
                 fracture.
28531.........  Treat sesamoid bone    CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 fracture.
28540.........  Treat foot            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28545.........  Treat foot             CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
28546.........  Treat foot             CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
28555.........  Repair foot            CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
28570.........  Treat foot            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28575.........  Treat foot            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28576.........  Treat foot             CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.

[[Page 68309]]

 
28585.........  Repair foot            CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
28600.........  Treat foot            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28605.........  Treat foot            ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28606.........  Treat foot             CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
28615.........  Repair foot            CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
28630.........  Treat toe             ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28635.........  Treat toe             ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
28636.........  Treat toe              CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
28645.........  Repair toe             CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
28660.........  Treat toe             ......  T             0043      1.6857      103.62  ..........       20.72
                 dislocation.
28665.........  Treat toe             ......  T             0045     14.5947      897.11      268.47      179.42
                 dislocation.
28666.........  Treat toe              CH...  T             0062     25.5264    1,569.06      372.87      313.81
                 dislocation.
28675.........  Repair of toe          CH...  T             0063     37.5382    2,307.40      548.33      461.48
                 dislocation.
28705.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28715.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28725.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28730.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28735.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28737.........  Revision of foot      ......  T             0056     40.8559    2,511.33  ..........      502.27
                 bones.
28740.........  Fusion of foot bones  ......  T             0056     40.8559    2,511.33  ..........      502.27
28750.........  Fusion of big toe     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 joint.
28755.........  Fusion of big toe     ......  T             0055     20.4263    1,255.56      355.34      251.11
                 joint.
28760.........  Fusion of big toe     ......  T             0056     40.8559    2,511.33  ..........      502.27
                 joint.
28810.........  Amputation toe &      ......  T             0055     20.4263    1,255.56      355.34      251.11
                 metatarsal.
28820.........  Amputation of toe...  ......  T             0055     20.4263    1,255.56      355.34      251.11
28825.........  Partial amputation    ......  T             0055     20.4263    1,255.56      355.34      251.11
                 of toe.
28890.........  High energy eswt,      CH...  T             0050     25.1296    1,544.67  ..........      308.93
                 plantar f.
28899.........  Foot/toes surgery     ......  T             0043      1.6857      103.62  ..........       20.72
                 procedure.
29000.........  Application of body   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29010.........  Application of body   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29015.........  Application of body   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29020.........  Application of body   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29025.........  Application of body   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29035.........  Application of body   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29040.........  Application of body   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29044.........  Application of body   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29046.........  Application of body   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29049.........  Application of        ......  S             0058      1.0607       65.20  ..........       13.04
                 figure eight.
29055.........  Application of        ......  S             0426      2.2777      140.01  ..........       28.00
                 shoulder cast.
29058.........  Application of        ......  S             0058      1.0607       65.20  ..........       13.04
                 shoulder cast.
29065.........  Application of long   ......  S             0426      2.2777      140.01  ..........       28.00
                 arm cast.
29075.........  Application of        ......  S             0426      2.2777      140.01  ..........       28.00
                 forearm cast.
29085.........  Apply hand/wrist      ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29086.........  Apply finger cast...  ......  S             0058      1.0607       65.20  ..........       13.04
29105.........  Apply long arm        ......  S             0058      1.0607       65.20  ..........       13.04
                 splint.
29125.........  Apply forearm splint  ......  S             0058      1.0607       65.20  ..........       13.04
29126.........  Apply forearm splint  ......  S             0058      1.0607       65.20  ..........       13.04
29130.........  Application of        ......  S             0058      1.0607       65.20  ..........       13.04
                 finger splint.
29131.........  Application of        ......  S             0058      1.0607       65.20  ..........       13.04
                 finger splint.
29200.........  Strapping of chest..  ......  S             0058      1.0607       65.20  ..........       13.04
29220.........  Strapping of low      ......  S             0058      1.0607       65.20  ..........       13.04
                 back.
29240.........  Strapping of          ......  S             0058      1.0607       65.20  ..........       13.04
                 shoulder.
29260.........  Strapping of elbow    ......  S             0058      1.0607       65.20  ..........       13.04
                 or wrist.
29280.........  Strapping of hand or  ......  S             0058      1.0607       65.20  ..........       13.04
                 finger.
29305.........  Application of hip    ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29325.........  Application of hip    ......  S             0426      2.2777      140.01  ..........       28.00
                 casts.
29345.........  Application of long   ......  S             0426      2.2777      140.01  ..........       28.00
                 leg cast.
29355.........  Application of long   ......  S             0426      2.2777      140.01  ..........       28.00
                 leg cast.
29358.........  Apply long leg cast   ......  S             0426      2.2777      140.01  ..........       28.00
                 brace.
29365.........  Application of long   ......  S             0426      2.2777      140.01  ..........       28.00
                 leg cast.
29405.........  Apply short leg cast  ......  S             0426      2.2777      140.01  ..........       28.00
29425.........  Apply short leg cast  ......  S             0426      2.2777      140.01  ..........       28.00
29435.........  Apply short leg cast  ......  S             0426      2.2777      140.01  ..........       28.00
29440.........  Addition of walker    ......  S             0058      1.0607       65.20  ..........       13.04
                 to cast.
29445.........  Apply rigid leg cast  ......  S             0426      2.2777      140.01  ..........       28.00
29450.........  Application of leg    ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29505.........  Application, long     ......  S             0058      1.0607       65.20  ..........       13.04
                 leg splint.
29515.........  Application lower     ......  S             0058      1.0607       65.20  ..........       13.04
                 leg splint.
29520.........  Strapping of hip....  ......  S             0058      1.0607       65.20  ..........       13.04
29530.........  Strapping of knee...  ......  S             0058      1.0607       65.20  ..........       13.04

[[Page 68310]]

 
29540.........  Strapping of ankle    ......  S             0058      1.0607       65.20  ..........       13.04
                 and/or ft.
29550.........  Strapping of toes...  ......  S             0058      1.0607       65.20  ..........       13.04
29580.........  Application of paste  ......  S             0058      1.0607       65.20  ..........       13.04
                 boot.
29590.........  Application of foot   ......  S             0058      1.0607       65.20  ..........       13.04
                 splint.
29700.........  Removal/revision of   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29705.........  Removal/revision of   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29710.........  Removal/revision of   ......  S             0426      2.2777      140.01  ..........       28.00
                 cast.
29715.........  Removal/revision of   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29720.........  Repair of body cast.  ......  S             0058      1.0607       65.20  ..........       13.04
29730.........  Windowing of cast...  ......  S             0058      1.0607       65.20  ..........       13.04
29740.........  Wedging of cast.....  ......  S             0058      1.0607       65.20  ..........       13.04
29750.........  Wedging of clubfoot   ......  S             0058      1.0607       65.20  ..........       13.04
                 cast.
29799.........  Casting/strapping     ......  S             0058      1.0607       65.20  ..........       13.04
                 procedure.
29800.........  Jaw arthroscopy/      ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29804.........  Jaw arthroscopy/      ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29805.........  Shoulder              ......  T             0041     28.6245    1,759.49  ..........      351.90
                 arthroscopy, dx.
29806.........  Shoulder arthroscopy/ ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29807.........  Shoulder arthroscopy/ ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29819.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29820.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29821.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29822.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29823.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29824.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29825.........  Shoulder arthroscopy/ ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29826.........  Shoulder arthroscopy/ ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29827.........  Arthroscop rotator    ......  T             0042     45.5027    2,796.96      804.74      559.39
                 cuff repr.
29830.........  Elbow arthroscopy...  ......  T             0041     28.6245    1,759.49  ..........      351.90
29834.........  Elbow arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29835.........  Elbow arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29836.........  Elbow arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29837.........  Elbow arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29838.........  Elbow arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29840.........  Wrist arthroscopy...  ......  T             0041     28.6245    1,759.49  ..........      351.90
29843.........  Wrist arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29844.........  Wrist arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29845.........  Wrist arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29846.........  Wrist arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29847.........  Wrist arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29848.........  Wrist endoscopy/      ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29850.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29851.........  Knee arthroscopy/     ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29855.........  Tibial arthroscopy/   ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29856.........  Tibial arthroscopy/   ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29860.........  Hip arthroscopy, dx.  ......  T             0041     28.6245    1,759.49  ..........      351.90
29861.........  Hip arthroscopy/      ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29862.........  Hip arthroscopy/      ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29863.........  Hip arthroscopy/      ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29866.........  Autgrft implnt, knee  ......  T             0042     45.5027    2,796.96      804.74      559.39
                 w/scope.
29867.........  Allgrft implnt, knee  ......  T             0042     45.5027    2,796.96      804.74      559.39
                 w/scope.
29868.........  Meniscal trnspl,      ......  T             0042     45.5027    2,796.96      804.74      559.39
                 knee w/scpe.
29870.........  Knee arthroscopy, dx  ......  T             0041     28.6245    1,759.49  ..........      351.90
29871.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 drainage.
29873.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29874.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29875.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29876.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29877.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29879.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29880.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29881.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29882.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29883.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29884.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29885.........  Knee arthroscopy/     ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29886.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29887.........  Knee arthroscopy/     ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29888.........  Knee arthroscopy/     ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29889.........  Knee arthroscopy/     ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29891.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.

[[Page 68311]]

 
29892.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29893.........  Scope, plantar        ......  T             0055     20.4263    1,255.56      355.34      251.11
                 fasciotomy.
29894.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29895.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29897.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29898.........  Ankle arthroscopy/    ......  T             0041     28.6245    1,759.49  ..........      351.90
                 surgery.
29899.........  Ankle arthroscopy/    ......  T             0042     45.5027    2,796.96      804.74      559.39
                 surgery.
29900.........  Mcp joint             ......  T             0053      16.154      992.95      253.49      198.59
                 arthroscopy, dx.
29901.........  Mcp joint             ......  T             0053      16.154      992.95      253.49      198.59
                 arthroscopy, surg.
29902.........  Mcp joint             ......  T             0053      16.154      992.95      253.49      198.59
                 arthroscopy, surg.
29999.........  Arthroscopy of joint  ......  T             0041     28.6245    1,759.49  ..........      351.90
30000.........  Drainage of nose      ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
30020.........  Drainage of nose      ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
30100.........  Intranasal biopsy...  ......  T             0252      7.5511      464.15      109.16       92.83
30110.........  Removal of nose       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 polyp(s).
30115.........  Removal of nose       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 polyp(s).
30117.........  Removal of            ......  T             0253     16.4266    1,009.71      282.29      201.94
                 intranasal lesion.
30118.........  Removal of            ......  T             0254     23.3299    1,434.04      321.35      286.81
                 intranasal lesion.
30120.........  Revision of nose....  ......  T             0253     16.4266    1,009.71      282.29      201.94
30124.........  Removal of nose       ......  T             0252      7.5511      464.15      109.16       92.83
                 lesion.
30125.........  Removal of nose       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
30130.........  Excise inferior       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 turbinate.
30140.........  Resect inferior       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 turbinate.
30150.........  Partial removal of    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nose.
30160.........  Removal of nose.....  ......  T             0256     38.1991    2,348.02  ..........      469.60
30200.........  Injection treatment   ......  T             0252      7.5511      464.15      109.16       92.83
                 of nose.
30210.........  Nasal sinus therapy.  ......  T             0252      7.5511      464.15      109.16       92.83
30220.........  Insert nasal septal   ......  T             0252      7.5511      464.15      109.16       92.83
                 button.
30300.........  Remove nasal foreign  ......  X             0340      0.6102       37.51  ..........        7.50
                 body.
30310.........  Remove nasal foreign  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 body.
30320.........  Remove nasal foreign  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 body.
30400.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nose.
30410.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nose.
30420.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nose.
30430.........  Revision of nose....  ......  T             0254     23.3299    1,434.04      321.35      286.81
30435.........  Revision of nose....  ......  T             0256     38.1991    2,348.02  ..........      469.60
30450.........  Revision of nose....  ......  T             0256     38.1991    2,348.02  ..........      469.60
30460.........  Revision of nose....  ......  T             0256     38.1991    2,348.02  ..........      469.60
30462.........  Revision of nose....  ......  T             0256     38.1991    2,348.02  ..........      469.60
30465.........  Repair nasal          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 stenosis.
30520.........  Repair of nasal       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 septum.
30540.........  Repair nasal defect.  ......  T             0256     38.1991    2,348.02  ..........      469.60
30545.........  Repair nasal defect.  ......  T             0256     38.1991    2,348.02  ..........      469.60
30560.........  Release of nasal      ......  T             0251       2.452      150.72  ..........       30.14
                 adhesions.
30580.........  Repair upper jaw      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fistula.
30600.........  Repair mouth/nose     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fistula.
30620.........  Intranasal            ......  T             0256     38.1991    2,348.02  ..........      469.60
                 reconstruction.
30630.........  Repair nasal septum   ......  T             0254     23.3299    1,434.04      321.35      286.81
                 defect.
30801.........  Ablate inf            ......  T             0252      7.5511      464.15      109.16       92.83
                 turbinate, superf.
30802.........  Cauterization, inner  ......  T             0252      7.5511      464.15      109.16       92.83
                 nose.
30901.........  Control of nosebleed  ......  T             0250      1.1791       72.48       25.39       14.50
30903.........  Control of nosebleed  ......  T             0250      1.1791       72.48       25.39       14.50
30905.........  Control of nosebleed  ......  T             0250      1.1791       72.48       25.39       14.50
30906.........  Repeat control of     ......  T             0250      1.1791       72.48       25.39       14.50
                 nosebleed.
30915.........  Ligation, nasal        CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 sinus artery.
30920.........  Ligation, upper jaw   ......  T             0092     24.8809    1,529.38      309.87      305.88
                 artery.
30930.........  Ther fx, nasal inf    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 turbinate.
30999.........  Nasal surgery         ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
31000.........  Irrigation,           ......  T             0251       2.452      150.72  ..........       30.14
                 maxillary sinus.
31002.........  Irrigation, sphenoid  ......  T             0252      7.5511      464.15      109.16       92.83
                 sinus.
31020.........  Exploration,          ......  T             0254     23.3299    1,434.04      321.35      286.81
                 maxillary sinus.
31030.........  Exploration,          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 maxillary sinus.
31032.........  Explore sinus,        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 remove polyps.
31040.........  Exploration behind    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 upper jaw.
31050.........  Exploration,          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sphenoid sinus.
31051.........  Sphenoid sinus        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 surgery.
31070.........  Exploration of        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 frontal sinus.
31075.........  Exploration of        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 frontal sinus.
31080.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31081.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.

[[Page 68312]]

 
31084.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31085.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31086.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31087.........  Removal of frontal    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31090.........  Exploration of        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinuses.
31200.........  Removal of ethmoid    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31201.........  Removal of ethmoid    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31205.........  Removal of ethmoid    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 sinus.
31231.........  Nasal endoscopy, dx.  ......  T             0072      1.4054       86.39       21.27       17.28
31233.........  Nasal/sinus           ......  T             0072      1.4054       86.39       21.27       17.28
                 endoscopy, dx.
31235.........  Nasal/sinus           ......  T             0074     14.7928      909.28      292.25      181.86
                 endoscopy, dx.
31237.........  Nasal/sinus            CH...  T             0074     14.7928      909.28      292.25      181.86
                 endoscopy, surg.
31238.........  Nasal/sinus           ......  T             0074     14.7928      909.28      292.25      181.86
                 endoscopy, surg.
31239.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31240.........  Nasal/sinus           ......  T             0074     14.7928      909.28      292.25      181.86
                 endoscopy, surg.
31254.........  Revision of ethmoid   ......  T             0075     21.9512    1,349.30      445.92      269.86
                 sinus.
31255.........  Removal of ethmoid    ......  T             0075     21.9512    1,349.30      445.92      269.86
                 sinus.
31256.........  Exploration           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 maxillary sinus.
31267.........  Endoscopy, maxillary  ......  T             0075     21.9512    1,349.30      445.92      269.86
                 sinus.
31276.........  Sinus endoscopy,      ......  T             0075     21.9512    1,349.30      445.92      269.86
                 surgical.
31287.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31288.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31292.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31293.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31294.........  Nasal/sinus           ......  T             0075     21.9512    1,349.30      445.92      269.86
                 endoscopy, surg.
31299.........  Sinus surgery         ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
31300.........  Removal of larynx     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
31320.........  Diagnostic incision,  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 larynx.
31400.........  Revision of larynx..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31420.........  Removal of            ......  T             0256     38.1991    2,348.02  ..........      469.60
                 epiglottis.
31500.........  Insert emergency      ......  S             0094      2.4233      148.96       46.29       29.79
                 airway.
31502.........  Change of windpipe    ......  T             0121      2.3587      144.98       43.80       29.00
                 airway.
31505.........  Diagnostic            ......  T             0071      0.7698       47.32       11.20        9.46
                 laryngoscopy.
31510.........  Laryngoscopy with     ......  T             0074     14.7928      909.28      292.25      181.86
                 biopsy.
31511.........  Remove foreign body,  ......  T             0072      1.4054       86.39       21.27       17.28
                 larynx.
31512.........  Removal of larynx     ......  T             0074     14.7928      909.28      292.25      181.86
                 lesion.
31513.........  Injection into vocal  ......  T             0072      1.4054       86.39       21.27       17.28
                 cord.
31515.........  Laryngoscopy for      ......  T             0074     14.7928      909.28      292.25      181.86
                 aspiration.
31520.........  Dx laryngoscopy,      ......  T             0072      1.4054       86.39       21.27       17.28
                 newborn.
31525.........  Dx laryngoscopy excl  ......  T             0074     14.7928      909.28      292.25      181.86
                 nb.
31526.........  Dx laryngoscopy w/    ......  T             0075     21.9512    1,349.30      445.92      269.86
                 oper scope.
31527.........  Laryngoscopy for      ......  T             0075     21.9512    1,349.30      445.92      269.86
                 treatment.
31528.........  Laryngoscopy and      ......  T             0074     14.7928      909.28      292.25      181.86
                 dilation.
31529.........  Laryngoscopy and      ......  T             0074     14.7928      909.28      292.25      181.86
                 dilation.
31530.........  Laryngoscopy w/fb     ......  T             0075     21.9512    1,349.30      445.92      269.86
                 removal.
31531.........  Laryngoscopy w/fb &   ......  T             0075     21.9512    1,349.30      445.92      269.86
                 op scope.
31535.........  Laryngoscopy w/       ......  T             0075     21.9512    1,349.30      445.92      269.86
                 biopsy.
31536.........  Laryngoscopy w/bx &   ......  T             0075     21.9512    1,349.30      445.92      269.86
                 op scope.
31540.........  Laryngoscopy w/exc    ......  T             0075     21.9512    1,349.30      445.92      269.86
                 of tumor.
31541.........  Larynscop w/tumr exc  ......  T             0075     21.9512    1,349.30      445.92      269.86
                 + scope.
31545.........  Remove vc lesion w/   ......  T             0075     21.9512    1,349.30      445.92      269.86
                 scope.
31546.........  Remove vc lesion      ......  T             0075     21.9512    1,349.30      445.92      269.86
                 scope/graft.
31560.........  Laryngoscop w/        ......  T             0075     21.9512    1,349.30      445.92      269.86
                 arytenoidectom.
31561.........  Larynscop, remve      ......  T             0075     21.9512    1,349.30      445.92      269.86
                 cart + scop.
31570.........  Laryngoscope w/vc     ......  T             0074     14.7928      909.28      292.25      181.86
                 inj.
31571.........  Laryngoscop w/vc inj  ......  T             0075     21.9512    1,349.30      445.92      269.86
                 + scope.
31575.........  Diagnostic            ......  T             0072      1.4054       86.39       21.27       17.28
                 laryngoscopy.
31576.........  Laryngoscopy with     ......  T             0075     21.9512    1,349.30      445.92      269.86
                 biopsy.
31577.........  Remove foreign body,  ......  T             0073      3.8463      236.42       69.15       47.28
                 larynx.
31578.........  Removal of larynx     ......  T             0075     21.9512    1,349.30      445.92      269.86
                 lesion.
31579.........  Diagnostic            ......  T             0073      3.8463      236.42       69.15       47.28
                 laryngoscopy.
31580.........  Revision of larynx..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31582.........  Revision of larynx..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31588.........  Revision of larynx..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31590.........  Reinnervate larynx..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31595.........  Larynx nerve surgery  ......  T             0256     38.1991    2,348.02  ..........      469.60
31599.........  Larynx surgery        ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
31600.........  Incision of windpipe  ......  T             0254     23.3299    1,434.04      321.35      286.81
31601.........  Incision of windpipe  ......  T             0254     23.3299    1,434.04      321.35      286.81
31603.........  Incision of windpipe  ......  T             0252      7.5511      464.15      109.16       92.83

[[Page 68313]]

 
31605.........  Incision of windpipe  ......  T             0252      7.5511      464.15      109.16       92.83
31610.........  Incision of windpipe  ......  T             0254     23.3299    1,434.04      321.35      286.81
31611.........  Surgery/speech        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 prosthesis.
31612.........  Puncture/clear        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 windpipe.
31613.........  Repair windpipe       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 opening.
31614.........  Repair windpipe       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 opening.
31615.........  Visualization of      ......  T             0076      9.5228      585.35      189.82      117.07
                 windpipe.
31620.........  Endobronchial us add- ......  S             0670     32.2854    1,984.52      536.10      396.90
                 on.
31622.........  Dx bronchoscope/wash  ......  T             0076      9.5228      585.35      189.82      117.07
31623.........  Dx bronchoscope/      ......  T             0076      9.5228      585.35      189.82      117.07
                 brush.
31624.........  Dx bronchoscope/      ......  T             0076      9.5228      585.35      189.82      117.07
                 lavage.
31625.........  Bronchoscopy w/       ......  T             0076      9.5228      585.35      189.82      117.07
                 biopsy(s).
31628.........  Bronchoscopy/lung     ......  T             0076      9.5228      585.35      189.82      117.07
                 bx, each.
31629.........  Bronchoscopy/needle   ......  T             0076      9.5228      585.35      189.82      117.07
                 bx, each.
31630.........  Bronchoscopy dilate/  ......  T             0415     22.0099    1,352.90      459.92      270.58
                 fx repr.
31631.........  Bronchoscopy, dilate  ......  T             0415     22.0099    1,352.90      459.92      270.58
                 w/stent.
31632.........  Bronchoscopy/lung     ......  T             0076      9.5228      585.35      189.82      117.07
                 bx, add'l.
31633.........  Bronchoscopy/needle   ......  T             0076      9.5228      585.35      189.82      117.07
                 bx add'l.
31635.........  Bronchoscopy w/fb     ......  T             0076      9.5228      585.35      189.82      117.07
                 removal.
31636.........  Bronchoscopy, bronch  ......  T             0415     22.0099    1,352.90      459.92      270.58
                 stents.
31637.........  Bronchoscopy, stent   ......  T             0076      9.5228      585.35      189.82      117.07
                 add-on.
31638.........  Bronchoscopy, revise  ......  T             0415     22.0099    1,352.90      459.92      270.58
                 stent.
31640.........  Bronchoscopy w/tumor  ......  T             0415     22.0099    1,352.90      459.92      270.58
                 excise.
31641.........  Bronchoscopy, treat   ......  T             0415     22.0099    1,352.90      459.92      270.58
                 blockage.
31643.........  Diag bronchoscope/    ......  T             0076      9.5228      585.35      189.82      117.07
                 catheter.
31645.........  Bronchoscopy, clear   ......  T             0076      9.5228      585.35      189.82      117.07
                 airways.
31646.........  Bronchoscopy,         ......  T             0076      9.5228      585.35      189.82      117.07
                 reclear airway.
31656.........  Bronchoscopy, inj     ......  T             0076      9.5228      585.35      189.82      117.07
                 for x-ray.
31700.........  Insertion of airway    CH...  D       ..........  ..........  ..........  ..........  ..........
                 catheter.
31708.........  Instill airway         CH...  D       ..........  ..........  ..........  ..........  ..........
                 contrast dye.
31710.........  Insertion of airway    CH...  D       ..........  ..........  ..........  ..........  ..........
                 catheter.
31715.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 bronchus x-ray.
31717.........  Bronchial brush       ......  T             0073      3.8463      236.42       69.15       47.28
                 biopsy.
31720.........  Clearance of airways  ......  T             0071      0.7698       47.32       11.20        9.46
31730.........  Intro, windpipe wire/ ......  T             0073      3.8463      236.42       69.15       47.28
                 tube.
31750.........  Repair of windpipe..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31755.........  Repair of windpipe..  ......  T             0256     38.1991    2,348.02  ..........      469.60
31785.........  Remove windpipe       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
31820.........  Closure of windpipe   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
31825.........  Repair of windpipe    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 defect.
31830.........  Revise windpipe scar  ......  T             0254     23.3299    1,434.04      321.35      286.81
31899.........  Airways surgical      ......  T             0076      9.5228      585.35      189.82      117.07
                 procedure.
32000.........  Drainage of chest...  ......  T             0070      3.6244      222.78  ..........       44.56
32002.........  Treatment of          ......  T             0070      3.6244      222.78  ..........       44.56
                 collapsed lung.
32005.........  Treat lung lining     ......  T             0070      3.6244      222.78  ..........       44.56
                 chemically.
32019.........  Insert pleural         CH...  T             0652     29.5416    1,815.86  ..........      363.17
                 catheter.
32020.........  Insertion of chest    ......  T             0070      3.6244      222.78  ..........       44.56
                 tube.
32201.........  Drain, percut, lung   ......  T             0070      3.6244      222.78  ..........       44.56
                 lesion.
32400.........  Needle biopsy chest   ......  T             0685      6.1384      377.32      115.47       75.46
                 lining.
32405.........  Biopsy, lung or       ......  T             0685      6.1384      377.32      115.47       75.46
                 mediastinum.
32420.........  Puncture/clear lung.  ......  T             0070      3.6244      222.78  ..........       44.56
32601.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32602.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32603.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32604.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32605.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32606.........  Thoracoscopy,         ......  T             0069     31.9442    1,963.55      591.64      392.71
                 diagnostic.
32960.........  Therapeutic           ......  T             0070      3.6244      222.78  ..........       44.56
                 pneumothorax.
32998.........  Perq rf ablate tx,     NI...  T             0423     37.3604    2,296.47  ..........      459.29
                 pul tumor.
32999.........  Chest surgery         ......  T             0070      3.6244      222.78  ..........       44.56
                 procedure.
33010.........  Drainage of heart     ......  T             0070      3.6244      222.78  ..........       44.56
                 sac.
33011.........  Repeat drainage of    ......  T             0070      3.6244      222.78  ..........       44.56
                 heart sac.
33200.........  Insertion of heart     CH...  D       ..........  ..........  ..........  ..........  ..........
                 pacemaker.
33201.........  Insertion of heart     CH...  D       ..........  ..........  ..........  ..........  ..........
                 pacemaker.
33202.........  Insert epicard         NI...  C       ..........  ..........  ..........  ..........  ..........
                 eltrd, open.
33203.........  Insert epicard         NI...  C       ..........  ..........  ..........  ..........  ..........
                 eltrd, endo.
33206.........  Insertion of heart    ......  T             0089    123.6693    7,601.70    1,682.28    1,520.34
                 pacemaker.
33207.........  Insertion of heart    ......  T             0089    123.6693    7,601.70    1,682.28    1,520.34
                 pacemaker.
33208.........  Insertion of heart    ......  T             0655    152.6392    9,382.43  ..........    1,876.49
                 pacemaker.
33210.........  Insertion of heart    ......  T             0106     58.8594    3,617.97  ..........      723.59
                 electrode.

[[Page 68314]]

 
33211.........  Insertion of heart    ......  T             0106     58.8594    3,617.97  ..........      723.59
                 electrode.
33212.........  Insertion of pulse    ......  T             0090     98.3023    6,042.45    1,612.80    1,208.49
                 generator.
33213.........  Insertion of pulse    ......  T             0654    112.7719    6,931.86  ..........    1,386.37
                 generator.
33214.........  Upgrade of pacemaker  ......  T             0655    152.6392    9,382.43  ..........    1,876.49
                 system.
33215.........  Reposition pacing-    ......  T             0105     25.6142    1,574.45      370.40      314.89
                 defib lead.
33216.........  Insert lead pace-     ......  T             0106     58.8594    3,617.97  ..........      723.59
                 defib, one.
33217.........  Insert lead pace-     ......  T             0106     58.8594    3,617.97  ..........      723.59
                 defib, dual.
33218.........  Repair lead pace-      CH...  T             0105     25.6142    1,574.45      370.40      314.89
                 defib, one.
33220.........  Repair lead pace-      CH...  T             0105     25.6142    1,574.45      370.40      314.89
                 defib, dual.
33222.........  Revise pocket,        ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pacemaker.
33223.........  Revise pocket,        ......  T             0027     21.4302    1,317.27      329.72      263.45
                 pacing-defib.
33224.........  Insert pacing lead &  ......  T             0418    307.2828   18,888.06  ..........    3,777.61
                 connect.
33225.........  Lventric pacing lead  ......  T             0418    307.2828   18,888.06  ..........    3,777.61
                 add-on.
33226.........  Reposition l ventric  ......  T             0105     25.6142    1,574.45      370.40      314.89
                 lead.
33233.........  Removal of pacemaker  ......  T             0105     25.6142    1,574.45      370.40      314.89
                 system.
33234.........  Removal of pacemaker  ......  T             0105     25.6142    1,574.45      370.40      314.89
                 system.
33235.........  Removal pacemaker     ......  T             0105     25.6142    1,574.45      370.40      314.89
                 electrode.
33241.........  Remove pulse          ......  T             0105     25.6142    1,574.45      370.40      314.89
                 generator.
33244.........  Remove eltrd,         ......  T             0105     25.6142    1,574.45      370.40      314.89
                 transven.
33245.........  Insert epic eltrd      CH...  D       ..........  ..........  ..........  ..........  ..........
                 pace-defib.
33246.........  Insert epic eltrd/     CH...  D       ..........  ..........  ..........  ..........  ..........
                 generator.
33253.........  Reconstruct atria...   CH...  D       ..........  ..........  ..........  ..........  ..........
33254.........  Ablate atria, lmtd..   NI...  C       ..........  ..........  ..........  ..........  ..........
33255.........  Ablate atria w/o       NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass, ext.
33256.........  Ablate atria w/        NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass, exten.
33265.........  Ablate atria w/        NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass, endo.
33266.........  Ablate atria w/o       NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass endo.
33282.........  Implant pat-active    ......  S             0680     72.6022    4,462.71  ..........      892.54
                 ht record.
33284.........  Remove pat-active ht  ......  T             0109     10.9918      675.64  ..........      135.13
                 record.
33508.........  Endoscopic vein       ......  N       ..........  ..........  ..........  ..........  ..........
                 harvest.
33675.........  Close mult vsd......   NI...  C       ..........  ..........  ..........  ..........  ..........
33676.........  Close mult vsd w/      NI...  C       ..........  ..........  ..........  ..........  ..........
                 resection.
33677.........  Cl mult vsd w/rem      NI...  C       ..........  ..........  ..........  ..........  ..........
                 pul band.
33724.........  Repair venous          NI...  C       ..........  ..........  ..........  ..........  ..........
                 anomaly.
33726.........  Repair pul venous      NI...  C       ..........  ..........  ..........  ..........  ..........
                 stenosis.
33999.........  Cardiac surgery       ......  T             0070      3.6244      222.78  ..........       44.56
                 procedure.
34101.........  Removal of artery     ......  T             0088     37.7391    2,319.75      655.22      463.95
                 clot.
34111.........  Removal of arm        ......  T             0088     37.7391    2,319.75      655.22      463.95
                 artery clot.
34201.........  Removal of artery     ......  T             0088     37.7391    2,319.75      655.22      463.95
                 clot.
34203.........  Removal of leg        ......  T             0088     37.7391    2,319.75      655.22      463.95
                 artery clot.
34421.........  Removal of vein clot  ......  T             0088     37.7391    2,319.75      655.22      463.95
34471.........  Removal of vein clot  ......  T             0088     37.7391    2,319.75      655.22      463.95
34490.........  Removal of vein clot  ......  T             0088     37.7391    2,319.75      655.22      463.95
34501.........  Repair valve,         ......  T             0088     37.7391    2,319.75      655.22      463.95
                 femoral vein.
34510.........  Transposition of      ......  T             0088     37.7391    2,319.75      655.22      463.95
                 vein valve.
34520.........  Cross-over vein       ......  T             0088     37.7391    2,319.75      655.22      463.95
                 graft.
34530.........  Leg vein fusion.....  ......  T             0088     37.7391    2,319.75      655.22      463.95
35011.........  Repair defect of      ......  T             0653     32.3818    1,990.44  ..........      398.09
                 artery.
35180.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35184.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35188.........  Repair blood vessel   ......  T             0088     37.7391    2,319.75      655.22      463.95
                 lesion.
35190.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35201.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35206.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35207.........  Repair blood vessel   ......  T             0088     37.7391    2,319.75      655.22      463.95
                 lesion.
35226.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35231.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35236.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35256.........  Repair blood vessel   ......  T             0093     22.8653    1,405.48  ..........      281.10
                 lesion.
35261.........  Repair blood vessel   ......  T             0653     32.3818    1,990.44  ..........      398.09
                 lesion.
35266.........  Repair blood vessel   ......  T             0653     32.3818    1,990.44  ..........      398.09
                 lesion.
35286.........  Repair blood vessel   ......  T             0653     32.3818    1,990.44  ..........      398.09
                 lesion.
35302.........  Rechanneling of        NI...  C       ..........  ..........  ..........  ..........  ..........
                 artery.
35303.........  Rechanneling of        NI...  C       ..........  ..........  ..........  ..........  ..........
                 artery.
35304.........  Rechanneling of        NI...  C       ..........  ..........  ..........  ..........  ..........
                 artery.
35305.........  Rechanneling of        NI...  C       ..........  ..........  ..........  ..........  ..........
                 artery.
35306.........  Rechanneling of        NI...  C       ..........  ..........  ..........  ..........  ..........
                 artery.
35321.........  Rechanneling of       ......  T             0093     22.8653    1,405.48  ..........      281.10
                 artery.
35381.........  Rechanneling of        CH...  D       ..........  ..........  ..........  ..........  ..........
                 artery.
35458.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.

[[Page 68315]]

 
35459.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35460.........  Repair venous         ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35470.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35471.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35472.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35473.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35474.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35475.........  Repair arterial       ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35476.........  Repair venous         ......  T             0081      42.936    2,639.19  ..........      527.84
                 blockage.
35484.........  Atherectomy, open...  ......  T             0081      42.936    2,639.19  ..........      527.84
35485.........  Atherectomy, open...  ......  T             0081      42.936    2,639.19  ..........      527.84
35490.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35491.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35492.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35493.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35494.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35495.........  Atherectomy,          ......  T             0081      42.936    2,639.19  ..........      527.84
                 percutaneous.
35500.........  Harvest vein for      ......  T             0081      42.936    2,639.19  ..........      527.84
                 bypass.
35507.........  Artery bypass graft.   CH...  D       ..........  ..........  ..........  ..........  ..........
35537.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35538.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35539.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35540.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35541.........  Artery bypass graft.   CH...  D       ..........  ..........  ..........  ..........  ..........
35546.........  Artery bypass graft.   CH...  D       ..........  ..........  ..........  ..........  ..........
35572.........  Harvest               ......  N       ..........  ..........  ..........  ..........  ..........
                 femoropopliteal
                 vein.
35637.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35638.........  Artery bypass graft.   NI...  C       ..........  ..........  ..........  ..........  ..........
35641.........  Artery bypass graft.   CH...  D       ..........  ..........  ..........  ..........  ..........
35685.........  Bypass graft patency/ ......  T             0093     22.8653    1,405.48  ..........      281.10
                 patch.
35686.........  Bypass graft/av fist  ......  T             0093     22.8653    1,405.48  ..........      281.10
                 patency.
35761.........  Exploration of        ......  T             0115     29.2133    1,795.68      374.81      359.14
                 artery/vein.
35860.........  Explore limb vessels  ......  T             0093     22.8653    1,405.48  ..........      281.10
35875.........  Removal of clot in    ......  T             0088     37.7391    2,319.75      655.22      463.95
                 graft.
35876.........  Removal of clot in    ......  T             0088     37.7391    2,319.75      655.22      463.95
                 graft.
35879.........  Revise graft w/vein.  ......  T             0088     37.7391    2,319.75      655.22      463.95
35881.........  Revise graft w/vein.  ......  T             0088     37.7391    2,319.75      655.22      463.95
35883.........  Revise graft w/        NI...  T             0088     37.7391    2,319.75      655.22      463.95
                 nonauto graft.
35884.........  Revise graft w/vein.   NI...  T             0088     37.7391    2,319.75      655.22      463.95
35903.........  Excision, graft,      ......  T             0115     29.2133    1,795.68      374.81      359.14
                 extremity.
36000.........  Place needle in vein  ......  N       ..........  ..........  ..........  ..........  ..........
36002.........  Pseudoaneurysm        ......  S             0267      2.4606      151.25       60.50       30.25
                 injection trt.
36005.........  Injection ext         ......  N       ..........  ..........  ..........  ..........  ..........
                 venography.
36010.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein.
36011.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein.
36012.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 vein.
36013.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36014.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36015.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36100.........  Establish access to   ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36120.........  Establish access to   ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36140.........  Establish access to   ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36145.........  Artery to vein shunt  ......  N       ..........  ..........  ..........  ..........  ..........
36160.........  Establish access to   ......  N       ..........  ..........  ..........  ..........  ..........
                 aorta.
36200.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 aorta.
36215.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36216.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36217.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36218.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36245.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36246.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36247.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36248.........  Place catheter in     ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36260.........  Insertion of          ......  T             0623     28.5032    1,752.03  ..........      350.41
                 infusion pump.
36261.........  Revision of infusion  ......  T             0623     28.5032    1,752.03  ..........      350.41
                 pump.
36262.........  Removal of infusion   ......  T             0622     22.6665    1,393.26  ..........      278.65
                 pump.
36299.........  Vessel injection      ......  N       ..........  ..........  ..........  ..........  ..........
                 procedure.
36400.........  Bl draw < 3 yrs fem/  ......  N       ..........  ..........  ..........  ..........  ..........
                 jugular.
36405.........  Bl draw < 3 yrs       ......  N       ..........  ..........  ..........  ..........  ..........
                 scalp vein.
36406.........  Bl draw < 3 yrs       ......  N       ..........  ..........  ..........  ..........  ..........
                 other vein.

[[Page 68316]]

 
36410.........  Non-routine bl draw   ......  N       ..........  ..........  ..........  ..........  ..........
                 > 3 yrs.
36416.........  Capillary blood draw  ......  N       ..........  ..........  ..........  ..........  ..........
36420.........  Vein access cutdown   ......  T             0035      0.1999       12.29  ..........        2.46
                 < 1 yr.
36425.........  Vein access cutdown   ......  T             0035      0.1999       12.29  ..........        2.46
                 > 1 yr.
36430.........  Blood transfusion     ......  S             0110      3.4584      212.58  ..........       42.52
                 service.
36440.........  Bl push transfuse, 2  ......  S             0110      3.4584      212.58  ..........       42.52
                 yr or <.
36450.........  Bl exchange/          ......  S             0110      3.4584      212.58  ..........       42.52
                 transfuse, nb.
36455.........  Bl exchange/          ......  S             0110      3.4584      212.58  ..........       42.52
                 transfuse non-nb.
36460.........  Transfusion service,  ......  S             0110      3.4584      212.58  ..........       42.52
                 fetal.
36468.........  Injection(s), spider  ......  T             0098      1.0798       66.37  ..........       13.27
                 veins.
36469.........  Injection(s), spider  ......  T             0098      1.0798       66.37  ..........       13.27
                 veins.
36470.........  Injection therapy of  ......  T             0098      1.0798       66.37  ..........       13.27
                 vein.
36471.........  Injection therapy of  ......  T             0098      1.0798       66.37  ..........       13.27
                 veins.
36475.........  Endovenous rf, 1st    ......  T             0091     34.7288    2,134.71  ..........      426.94
                 vein.
36476.........  Endovenous rf, vein   ......  T             0091     34.7288    2,134.71  ..........      426.94
                 add-on.
36478.........  Endovenous laser,      CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 1st vein.
36479.........  Endovenous laser       CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 vein addon.
36481.........  Insertion of          ......  N       ..........  ..........  ..........  ..........  ..........
                 catheter, vein.
36500.........  Insertion of          ......  N       ..........  ..........  ..........  ..........  ..........
                 catheter, vein.
36510.........  Insertion of          ......  N       ..........  ..........  ..........  ..........  ..........
                 catheter, vein.
36511.........  Apheresis wbc.......  ......  S             0111     11.7134      720.00      198.40      144.00
36512.........  Apheresis rbc.......  ......  S             0111     11.7134      720.00      198.40      144.00
36513.........  Apheresis platelets.  ......  S             0111     11.7134      720.00      198.40      144.00
36514.........  Apheresis plasma....  ......  S             0111     11.7134      720.00      198.40      144.00
36515.........  Apheresis, adsorp/    ......  S             0112     30.2231    1,857.75      433.29      371.55
                 reinfuse.
36516.........  Apheresis, selective  ......  S             0112     30.2231    1,857.75      433.29      371.55
36522.........  Photopheresis.......  ......  S             0112     30.2231    1,857.75      433.29      371.55
36540.........  Collect blood venous   CH...  Q             0624      0.5145       31.63       12.65        6.33
                 device.
36550.........  Declot vascular       ......  T             0676      2.0726      127.40  ..........       25.48
                 device.
36555.........  Insert non-tunnel cv  ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36556.........  Insert non-tunnel cv  ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36557.........  Insert tunneled cv    ......  T             0622     22.6665    1,393.26  ..........      278.65
                 cath.
36558.........  Insert tunneled cv    ......  T             0622     22.6665    1,393.26  ..........      278.65
                 cath.
36560.........  Insert tunneled cv    ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36561.........  Insert tunneled cv    ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36563.........  Insert tunneled cv    ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36565.........  Insert tunneled cv    ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36566.........  Insert tunneled cv     CH...  T             0625     83.4609    5,130.17  ..........    1,026.03
                 cath.
36568.........  Insert picc cath....  ......  T             0621      8.7846      539.97  ..........      107.99
36569.........  Insert picc cath....  ......  T             0621      8.7846      539.97  ..........      107.99
36570.........  Insert picvad cath..  ......  T             0622     22.6665    1,393.26  ..........      278.65
36571.........  Insert picvad cath..  ......  T             0622     22.6665    1,393.26  ..........      278.65
36575.........  Repair tunneled cv    ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36576.........  Repair tunneled cv    ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36578.........  Replace tunneled cv   ......  T             0622     22.6665    1,393.26  ..........      278.65
                 cath.
36580.........  Replace cvad cath...  ......  T             0621      8.7846      539.97  ..........      107.99
36581.........  Replace tunneled cv   ......  T             0622     22.6665    1,393.26  ..........      278.65
                 cath.
36582.........  Replace tunneled cv   ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36583.........  Replace tunneled cv   ......  T             0623     28.5032    1,752.03  ..........      350.41
                 cath.
36584.........  Replace picc cath...  ......  T             0621      8.7846      539.97  ..........      107.99
36585.........  Replace picvad cath.  ......  T             0622     22.6665    1,393.26  ..........      278.65
36589.........  Removal tunneled cv   ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36590.........  Removal tunneled cv   ......  T             0621      8.7846      539.97  ..........      107.99
                 cath.
36595.........  Mech remov tunneled   ......  T             0622     22.6665    1,393.26  ..........      278.65
                 cv cath.
36596.........  Mech remov tunneled   ......  T             0621      8.7846      539.97  ..........      107.99
                 cv cath.
36597.........  Reposition venous     ......  T             0621      8.7846      539.97  ..........      107.99
                 catheter.
36598.........  Inj w/fluor, eval cv  ......  X             0340      0.6102       37.51  ..........        7.50
                 device.
36600.........  Withdrawal of          CH...  Q             0035      0.1999       12.29  ..........        2.46
                 arterial blood.
36620.........  Insertion catheter,   ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36625.........  Insertion catheter,   ......  N       ..........  ..........  ..........  ..........  ..........
                 artery.
36640.........  Insertion catheter,   ......  T             0623     28.5032    1,752.03  ..........      350.41
                 artery.
36680.........  Insert needle, bone   ......  T             0002      1.0995       67.58  ..........       13.52
                 cavity.
36800.........  Insertion of cannula  ......  T             0115     29.2133    1,795.68      374.81      359.14
36810.........  Insertion of cannula  ......  T             0115     29.2133    1,795.68      374.81      359.14
36815.........  Insertion of cannula  ......  T             0115     29.2133    1,795.68      374.81      359.14
36818.........  Av fuse, uppr arm,    ......  T             0088     37.7391    2,319.75      655.22      463.95
                 cephalic.
36819.........  Av fuse, uppr arm,    ......  T             0088     37.7391    2,319.75      655.22      463.95
                 basilic.
36820.........  Av fusion/forearm     ......  T             0088     37.7391    2,319.75      655.22      463.95
                 vein.
36821.........  Av fusion direct any  ......  T             0088     37.7391    2,319.75      655.22      463.95
                 site.
36825.........  Artery-vein           ......  T             0088     37.7391    2,319.75      655.22      463.95
                 autograft.

[[Page 68317]]

 
36830.........  Artery-vein           ......  T             0088     37.7391    2,319.75      655.22      463.95
                 nonautograft.
36831.........  Open thrombect av     ......  T             0088     37.7391    2,319.75      655.22      463.95
                 fistula.
36832.........  Av fistula revision,  ......  T             0088     37.7391    2,319.75      655.22      463.95
                 open.
36833.........  Av fistula revision.  ......  T             0088     37.7391    2,319.75      655.22      463.95
36834.........  Repair A-V aneurysm.  ......  T             0088     37.7391    2,319.75      655.22      463.95
36835.........  Artery to vein shunt  ......  T             0115     29.2133    1,795.68      374.81      359.14
36838.........  Dist revas ligation,  ......  T             0088     37.7391    2,319.75      655.22      463.95
                 hemo.
36860.........  External cannula      ......  T             0676      2.0726      127.40  ..........       25.48
                 declotting.
36861.........  Cannula declotting..  ......  T             0115     29.2133    1,795.68      374.81      359.14
36870.........  Percut thrombect av   ......  T             0653     32.3818    1,990.44  ..........      398.09
                 fistula.
37183.........  Remove hepatic shunt  ......  T             0229     68.4697    4,208.70  ..........      841.74
                 (tips).
37184.........  Prim art mech          CH...  T             0088     37.7391    2,319.75      655.22      463.95
                 thrombectomy.
37185.........  Prim art m-thrombect   CH...  T             0088     37.7391    2,319.75      655.22      463.95
                 add-on.
37186.........  Sec art m-thrombect    CH...  T             0088     37.7391    2,319.75      655.22      463.95
                 add-on.
37187.........  Venous mech            CH...  T             0088     37.7391    2,319.75      655.22      463.95
                 thrombectomy.
37188.........  Venous m-              CH...  T             0088     37.7391    2,319.75      655.22      463.95
                 thrombectomy add-on.
37195.........  Thrombolytic          ......  T             0676      2.0726      127.40  ..........       25.48
                 therapy, stroke.
37200.........  Transcatheter biopsy  ......  T             0685      6.1384      377.32      115.47       75.46
37201.........  Transcatheter         ......  T             0676      2.0726      127.40  ..........       25.48
                 therapy infuse.
37202.........  Transcatheter         ......  T             0676      2.0726      127.40  ..........       25.48
                 therapy infuse.
37203.........  Transcatheter         ......  T             0103     16.2375      998.09      223.63      199.62
                 retrieval.
37204.........  Transcatheter         ......  T             0115     29.2133    1,795.68      374.81      359.14
                 occlusion.
37205.........  Transcath iv stent,   ......  T             0229     68.4697    4,208.70  ..........      841.74
                 percut.
37206.........  Transcath iv stent/   ......  T             0229     68.4697    4,208.70  ..........      841.74
                 perc addl.
37207.........  Transcath iv stent,   ......  T             0229     68.4697    4,208.70  ..........      841.74
                 open.
37208.........  Transcath iv stent/   ......  T             0229     68.4697    4,208.70  ..........      841.74
                 open addl.
37209.........  Change iv cath at     ......  T             0103     16.2375      998.09      223.63      199.62
                 thromb tx.
37210.........  Embolization uterine   NI...  T             0202     42.9896    2,642.48      981.50      528.50
                 fibroid.
37250.........  Iv us first vessel    ......  S             0416     32.5472    2,000.61  ..........      400.12
                 add-on.
37251.........  Iv us each add        ......  S             0416     32.5472    2,000.61  ..........      400.12
                 vessel add-on.
37500.........  Endoscopy ligate       CH...  T             0091     34.7288    2,134.71  ..........      426.94
                 perf veins.
37501.........  Vascular endoscopy    ......  T             0092     24.8809    1,529.38      309.87      305.88
                 procedure.
37565.........  Ligation of neck      ......  T             0093     22.8653    1,405.48  ..........      281.10
                 vein.
37600.........  Ligation of neck      ......  T             0093     22.8653    1,405.48  ..........      281.10
                 artery.
37605.........  Ligation of neck      ......  T             0091     34.7288    2,134.71  ..........      426.94
                 artery.
37606.........  Ligation of neck       CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 artery.
37607.........  Ligation of a-v       ......  T             0092     24.8809    1,529.38      309.87      305.88
                 fistula.
37609.........  Temporal artery       ......  T             0021     15.1024      928.31      219.48      185.66
                 procedure.
37615.........  Ligation of neck       CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 artery.
37620.........  Revision of major     ......  T             0091     34.7288    2,134.71  ..........      426.94
                 vein.
37650.........  Revision of major      CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 vein.
37700.........  Revise leg vein.....  ......  T             0091     34.7288    2,134.71  ..........      426.94
37718.........  Ligate/strip short     CH...  T             0091     34.7288    2,134.71  ..........      426.94
                 leg vein.
37722.........  Ligate/strip long      CH...  T             0091     34.7288    2,134.71  ..........      426.94
                 leg vein.
37735.........  Removal of leg veins/  CH...  T             0091     34.7288    2,134.71  ..........      426.94
                 lesion.
37760.........  Ligation, leg veins,   CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 open.
37765.........  Phleb veins--extrem--  CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 to 20.
37766.........  Phleb veins--extrem    CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 20+.
37780.........  Revision of leg vein   CH...  T             0092     24.8809    1,529.38      309.87      305.88
37785.........  Ligate/divide/excise   CH...  T             0092     24.8809    1,529.38      309.87      305.88
                 vein.
37790.........  Penile venous         ......  T             0181     32.9873    2,027.66      621.82      405.53
                 occlusion.
37799.........  Vascular surgery      ......  T             0103     16.2375      998.09      223.63      199.62
                 procedure.
38120.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 splenectomy.
38129.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 spleen.
38200.........  Injection for spleen  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
38204.........  Bl donor search       ......  N       ..........  ..........  ..........  ..........  ..........
                 management.
38205.........  Harvest allogenic     ......  S             0111     11.7134      720.00      198.40      144.00
                 stem cells.
38206.........  Harvest auto stem     ......  S             0111     11.7134      720.00      198.40      144.00
                 cells.
38220.........  Bone marrow           ......  T             0003      2.4011      147.59  ..........       29.52
                 aspiration.
38221.........  Bone marrow biopsy..  ......  T             0003      2.4011      147.59  ..........       29.52
38230.........  Bone marrow           ......  S             0123     20.3582    1,251.38  ..........      250.28
                 collection.
38240.........  Bone marrow/stem      ......  S             0123     20.3582    1,251.38  ..........      250.28
                 transplant.
38241.........  Bone marrow/stem      ......  S             0123     20.3582    1,251.38  ..........      250.28
                 transplant.
38242.........  Lymphocyte infuse     ......  S             0111     11.7134      720.00      198.40      144.00
                 transplant.
38300.........  Drainage, lymph node  ......  T             0007     11.1535      685.58  ..........      137.12
                 lesion.
38305.........  Drainage, lymph node  ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
38308.........  Incision of lymph     ......  T             0113     21.2621    1,306.94  ..........      261.39
                 channels.
38500.........  Biopsy/removal,       ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lymph nodes.
38505.........  Needle biopsy, lymph  ......  T             0005      3.9045      240.00       71.59       48.00
                 nodes.
38510.........  Biopsy/removal,       ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lymph nodes.

[[Page 68318]]

 
38520.........  Biopsy/removal,       ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lymph nodes.
38525.........  Biopsy/removal,       ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lymph nodes.
38530.........  Biopsy/removal,       ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lymph nodes.
38542.........  Explore deep          ......  T             0114     37.7224    2,318.72      467.95      463.74
                 node(s), neck.
38550.........  Removal, neck/armpit  ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lesion.
38555.........  Removal, neck/armpit  ......  T             0113     21.2621    1,306.94  ..........      261.39
                 lesion.
38570.........  Laparoscopy, lymph    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 node biop.
38571.........  Laparoscopy,          ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 lymphadenectomy.
38572.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 lymphadenectomy.
38589.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 lymphatic.
38700.........  Removal of lymph      ......  T             0113     21.2621    1,306.94  ..........      261.39
                 nodes, neck.
38720.........  Removal of lymph      ......  T             0113     21.2621    1,306.94  ..........      261.39
                 nodes, neck.
38740.........  Remove armpit lymph   ......  T             0114     37.7224    2,318.72      467.95      463.74
                 nodes.
38745.........  Remove armpit lymph   ......  T             0114     37.7224    2,318.72      467.95      463.74
                 nodes.
38760.........  Remove groin lymph    ......  T             0113     21.2621    1,306.94  ..........      261.39
                 nodes.
38790.........  Inject for lymphatic  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
38792.........  Identify sentinel      CH...  Q             0389      1.3754       84.54       33.81       16.91
                 node.
38794.........  Access thoracic       ......  N       ..........  ..........  ..........  ..........  ..........
                 lymph duct.
38999.........  Blood/lymph system    ......  S             0110      3.4584      212.58  ..........       42.52
                 procedure.
39400.........  Visualization of      ......  T             0069     31.9442    1,963.55      591.64      392.71
                 chest.
40490.........  Biopsy of lip.......  ......  T             0251       2.452      150.72  ..........       30.14
40500.........  Partial excision of   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lip.
40510.........  Partial excision of   ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lip.
40520.........  Partial excision of   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lip.
40525.........  Reconstruct lip with  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 flap.
40527.........  Reconstruct lip with  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 flap.
40530.........  Partial removal of    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lip.
40650.........  Repair lip..........  ......  T             0252      7.5511      464.15      109.16       92.83
40652.........  Repair lip..........  ......  T             0252      7.5511      464.15      109.16       92.83
40654.........  Repair lip..........  ......  T             0252      7.5511      464.15      109.16       92.83
40700.........  Repair cleft lip/     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nasal.
40701.........  Repair cleft lip/     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nasal.
40702.........  Repair cleft lip/     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nasal.
40720.........  Repair cleft lip/     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nasal.
40761.........  Repair cleft lip/     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nasal.
40799.........  Lip surgery           ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
40800.........  Drainage of mouth      CH...  T             0006      1.4392       88.46  ..........       17.69
                 lesion.
40801.........  Drainage of mouth     ......  T             0252      7.5511      464.15      109.16       92.83
                 lesion.
40804.........  Removal, foreign      ......  X             0340      0.6102       37.51  ..........        7.50
                 body, mouth.
40805.........  Removal, foreign      ......  T             0252      7.5511      464.15      109.16       92.83
                 body, mouth.
40806.........  Incision of lip fold  ......  T             0251       2.452      150.72  ..........       30.14
40808.........  Biopsy of mouth       ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
40810.........  Excision of mouth     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
40812.........  Excise/repair mouth   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
40814.........  Excise/repair mouth   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
40816.........  Excision of mouth     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
40818.........  Excise oral mucosa    ......  T             0251       2.452      150.72  ..........       30.14
                 for graft.
40819.........  Excise lip or cheek   ......  T             0252      7.5511      464.15      109.16       92.83
                 fold.
40820.........  Treatment of mouth    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
40830.........  Repair mouth          ......  T             0251       2.452      150.72  ..........       30.14
                 laceration.
40831.........  Repair mouth          ......  T             0252      7.5511      464.15      109.16       92.83
                 laceration.
40840.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 mouth.
40842.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 mouth.
40843.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 mouth.
40844.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mouth.
40845.........  Reconstruction of     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mouth.
40899.........  Mouth surgery         ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
41000.........  Drainage of mouth     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41005.........  Drainage of mouth     ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
41006.........  Drainage of mouth     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
41007.........  Drainage of mouth     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41008.........  Drainage of mouth     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41009.........  Drainage of mouth     ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
41010.........  Incision of tongue    ......  T             0252      7.5511      464.15      109.16       92.83
                 fold.
41015.........  Drainage of mouth     ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
41016.........  Drainage of mouth     ......  T             0252      7.5511      464.15      109.16       92.83
                 lesion.
41017.........  Drainage of mouth     ......  T             0252      7.5511      464.15      109.16       92.83
                 lesion.
41018.........  Drainage of mouth     ......  T             0252      7.5511      464.15      109.16       92.83
                 lesion.
41100.........  Biopsy of tongue....  ......  T             0252      7.5511      464.15      109.16       92.83
41105.........  Biopsy of tongue....  ......  T             0253     16.4266    1,009.71      282.29      201.94

[[Page 68319]]

 
41108.........  Biopsy of floor of    ......  T             0252      7.5511      464.15      109.16       92.83
                 mouth.
41110.........  Excision of tongue    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41112.........  Excision of tongue    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41113.........  Excision of tongue    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41114.........  Excision of tongue    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
41115.........  Excision of tongue    ......  T             0252      7.5511      464.15      109.16       92.83
                 fold.
41116.........  Excision of mouth     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41120.........  Partial removal of    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 tongue.
41250.........  Repair tongue         ......  T             0251       2.452      150.72  ..........       30.14
                 laceration.
41251.........  Repair tongue         ......  T             0251       2.452      150.72  ..........       30.14
                 laceration.
41252.........  Repair tongue         ......  T             0252      7.5511      464.15      109.16       92.83
                 laceration.
41500.........  Fixation of tongue..  ......  T             0254     23.3299    1,434.04      321.35      286.81
41510.........  Tongue to lip         ......  T             0253     16.4266    1,009.71      282.29      201.94
                 surgery.
41520.........  Reconstruction,       ......  T             0252      7.5511      464.15      109.16       92.83
                 tongue fold.
41599.........  Tongue and mouth      ......  T             0251       2.452      150.72  ..........       30.14
                 surgery.
41800.........  Drainage of gum        CH...  T             0006      1.4392       88.46  ..........       17.69
                 lesion.
41805.........  Removal foreign       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 body, gum.
41806.........  Removal foreign       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 body,jawbone.
41820.........  Excision, gum, each   ......  T             0252      7.5511      464.15      109.16       92.83
                 quadrant.
41821.........  Excision of gum flap  ......  T             0252      7.5511      464.15      109.16       92.83
41822.........  Excision of gum       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41823.........  Excision of gum       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
41825.........  Excision of gum       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41826.........  Excision of gum       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41827.........  Excision of gum       ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion.
41828.........  Excision of gum       ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41830.........  Removal of gum        ......  T             0253     16.4266    1,009.71      282.29      201.94
                 tissue.
41850.........  Treatment of gum      ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
41870.........  Gum graft...........  ......  T             0254     23.3299    1,434.04      321.35      286.81
41872.........  Repair gum..........  ......  T             0253     16.4266    1,009.71      282.29      201.94
41874.........  Repair tooth socket.  ......  T             0254     23.3299    1,434.04      321.35      286.81
41899.........  Dental surgery        ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
42000.........  Drainage mouth roof   ......  T             0251       2.452      150.72  ..........       30.14
                 lesion.
42100.........  Biopsy roof of mouth  ......  T             0252      7.5511      464.15      109.16       92.83
42104.........  Excision lesion,      ......  T             0253     16.4266    1,009.71      282.29      201.94
                 mouth roof.
42106.........  Excision lesion,      ......  T             0253     16.4266    1,009.71      282.29      201.94
                 mouth roof.
42107.........  Excision lesion,      ......  T             0254     23.3299    1,434.04      321.35      286.81
                 mouth roof.
42120.........  Remove palate/lesion  ......  T             0256     38.1991    2,348.02  ..........      469.60
42140.........  Excision of uvula...  ......  T             0252      7.5511      464.15      109.16       92.83
42145.........  Repair palate,        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 pharynx/uvula.
42160.........  Treatment mouth roof  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
42180.........  Repair palate.......  ......  T             0251       2.452      150.72  ..........       30.14
42182.........  Repair palate.......  ......  T             0256     38.1991    2,348.02  ..........      469.60
42200.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42205.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42210.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42215.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42220.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42225.........  Reconstruct cleft     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42226.........  Lengthening of        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42227.........  Lengthening of        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 palate.
42235.........  Repair palate.......  ......  T             0253     16.4266    1,009.71      282.29      201.94
42260.........  Repair nose to lip    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 fistula.
42280.........  Preparation, palate   ......  T             0251       2.452      150.72  ..........       30.14
                 mold.
42281.........  Insertion, palate     ......  T             0253     16.4266    1,009.71      282.29      201.94
                 prosthesis.
42299.........  Palate/uvula surgery  ......  T             0251       2.452      150.72  ..........       30.14
42300.........  Drainage of salivary  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 gland.
42305.........  Drainage of salivary  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 gland.
42310.........  Drainage of salivary  ......  T             0251       2.452      150.72  ..........       30.14
                 gland.
42320.........  Drainage of salivary  ......  T             0251       2.452      150.72  ..........       30.14
                 gland.
42330.........  Removal of salivary   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 stone.
42335.........  Removal of salivary   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 stone.
42340.........  Removal of salivary   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 stone.
42400.........  Biopsy of salivary    ......  T             0005      3.9045      240.00       71.59       48.00
                 gland.
42405.........  Biopsy of salivary    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 gland.
42408.........  Excision of salivary  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 cyst.
42409.........  Drainage of salivary  ......  T             0253     16.4266    1,009.71      282.29      201.94
                 cyst.
42410.........  Excise parotid gland/ ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
42415.........  Excise parotid gland/ ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
42420.........  Excise parotid gland/ ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.

[[Page 68320]]

 
42425.........  Excise parotid gland/ ......  T             0256     38.1991    2,348.02  ..........      469.60
                 lesion.
42440.........  Excise submaxillary   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 gland.
42450.........  Excise sublingual     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 gland.
42500.........  Repair salivary duct  ......  T             0254     23.3299    1,434.04      321.35      286.81
42505.........  Repair salivary duct  ......  T             0256     38.1991    2,348.02  ..........      469.60
42507.........  Parotid duct          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 diversion.
42508.........  Parotid duct          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 diversion.
42509.........  Parotid duct          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 diversion.
42510.........  Parotid duct          ......  T             0256     38.1991    2,348.02  ..........      469.60
                 diversion.
42550.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 salivary x-ray.
42600.........  Closure of salivary   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 fistula.
42650.........  Dilation of salivary  ......  T             0252      7.5511      464.15      109.16       92.83
                 duct.
42660.........  Dilation of salivary  ......  T             0251       2.452      150.72  ..........       30.14
                 duct.
42665.........  Ligation of salivary  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 duct.
42699.........  Salivary surgery      ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
42700.........  Drainage of tonsil    ......  T             0251       2.452      150.72  ..........       30.14
                 abscess.
42720.........  Drainage of throat    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 abscess.
42725.........  Drainage of throat    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 abscess.
42800.........  Biopsy of throat....   CH...  T             0252      7.5511      464.15      109.16       92.83
42802.........  Biopsy of throat....  ......  T             0253     16.4266    1,009.71      282.29      201.94
42804.........  Biopsy of upper nose/ ......  T             0253     16.4266    1,009.71      282.29      201.94
                 throat.
42806.........  Biopsy of upper nose/ ......  T             0254     23.3299    1,434.04      321.35      286.81
                 throat.
42808.........  Excise pharynx        ......  T             0253     16.4266    1,009.71      282.29      201.94
                 lesion.
42809.........  Remove pharynx        ......  X             0340      0.6102       37.51  ..........        7.50
                 foreign body.
42810.........  Excision of neck      ......  T             0254     23.3299    1,434.04      321.35      286.81
                 cyst.
42815.........  Excision of neck      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 cyst.
42820.........  Remove tonsils and    ......  T             0258     22.1165    1,359.46      437.25      271.89
                 adenoids.
42821.........  Remove tonsils and    ......  T             0258     22.1165    1,359.46      437.25      271.89
                 adenoids.
42825.........  Removal of tonsils..  ......  T             0258     22.1165    1,359.46      437.25      271.89
42826.........  Removal of tonsils..  ......  T             0258     22.1165    1,359.46      437.25      271.89
42830.........  Removal of adenoids.  ......  T             0258     22.1165    1,359.46      437.25      271.89
42831.........  Removal of adenoids.  ......  T             0258     22.1165    1,359.46      437.25      271.89
42835.........  Removal of adenoids.  ......  T             0258     22.1165    1,359.46      437.25      271.89
42836.........  Removal of adenoids.  ......  T             0258     22.1165    1,359.46      437.25      271.89
42842.........  Extensive surgery of  ......  T             0254     23.3299    1,434.04      321.35      286.81
                 throat.
42844.........  Extensive surgery of  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 throat.
42860.........  Excision of tonsil    ......  T             0258     22.1165    1,359.46      437.25      271.89
                 tags.
42870.........  Excision of lingual   ......  T             0258     22.1165    1,359.46      437.25      271.89
                 tonsil.
42890.........  Partial removal of    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 pharynx.
42892.........  Revision of           ......  T             0256     38.1991    2,348.02  ..........      469.60
                 pharyngeal walls.
42900.........  Repair throat wound.  ......  T             0252      7.5511      464.15      109.16       92.83
42950.........  Reconstruction of     ......  T             0254     23.3299    1,434.04      321.35      286.81
                 throat.
42955.........  Surgical opening of   ......  T             0254     23.3299    1,434.04      321.35      286.81
                 throat.
42960.........  Control throat        ......  T             0250      1.1791       72.48       25.39       14.50
                 bleeding.
42962.........  Control throat        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bleeding.
42970.........  Control nose/throat   ......  T             0250      1.1791       72.48       25.39       14.50
                 bleeding.
42972.........  Control nose/throat   ......  T             0253     16.4266    1,009.71      282.29      201.94
                 bleeding.
42999.........  Throat surgery        ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
43020.........  Incision of           ......  T             0252      7.5511      464.15      109.16       92.83
                 esophagus.
43030.........  Throat muscle         ......  T             0253     16.4266    1,009.71      282.29      201.94
                 surgery.
43130.........  Removal of esophagus   CH...  T             0256     38.1991    2,348.02  ..........      469.60
                 pouch.
43200.........  Esophagus endoscopy.  ......  T             0141      8.3175      511.26      143.38      102.25
43201.........  Esoph scope w/        ......  T             0141      8.3175      511.26      143.38      102.25
                 submucous inj.
43202.........  Esophagus endoscopy,  ......  T             0141      8.3175      511.26      143.38      102.25
                 biopsy.
43204.........  Esoph scope w/        ......  T             0141      8.3175      511.26      143.38      102.25
                 sclerosis inj.
43205.........  Esophagus endoscopy/  ......  T             0141      8.3175      511.26      143.38      102.25
                 ligation.
43215.........  Esophagus endoscopy.  ......  T             0141      8.3175      511.26      143.38      102.25
43216.........  Esophagus endoscopy/  ......  T             0141      8.3175      511.26      143.38      102.25
                 lesion.
43217.........  Esophagus endoscopy.  ......  T             0141      8.3175      511.26      143.38      102.25
43219.........  Esophagus endoscopy.  ......  T             0384     22.9475    1,410.54      295.41      282.11
43220.........  Esoph endoscopy,      ......  T             0141      8.3175      511.26      143.38      102.25
                 dilation.
43226.........  Esoph endoscopy,      ......  T             0141      8.3175      511.26      143.38      102.25
                 dilation.
43227.........  Esoph endoscopy,      ......  T             0141      8.3175      511.26      143.38      102.25
                 repair.
43228.........  Esoph endoscopy,      ......  T             0422     25.7552    1,583.12      448.81      316.62
                 ablation.
43231.........  Esoph endoscopy w/us  ......  T             0141      8.3175      511.26      143.38      102.25
                 exam.
43232.........  Esoph endoscopy w/us  ......  T             0141      8.3175      511.26      143.38      102.25
                 fn bx.
43234.........  Upper GI endoscopy,   ......  T             0141      8.3175      511.26      143.38      102.25
                 exam.
43235.........  Uppr gi endoscopy,    ......  T             0141      8.3175      511.26      143.38      102.25
                 diagnosis.
43236.........  Uppr gi scope w/      ......  T             0141      8.3175      511.26      143.38      102.25
                 submuc inj.
43237.........  Endoscopic us exam,   ......  T             0141      8.3175      511.26      143.38      102.25
                 esoph.

[[Page 68321]]

 
43238.........  Uppr gi endoscopy w/  ......  T             0141      8.3175      511.26      143.38      102.25
                 us fn bx.
43239.........  Upper GI endoscopy,   ......  T             0141      8.3175      511.26      143.38      102.25
                 biopsy.
43240.........  Esoph endoscope w/    ......  T             0141      8.3175      511.26      143.38      102.25
                 drain cyst.
43241.........  Upper GI endoscopy    ......  T             0141      8.3175      511.26      143.38      102.25
                 with tube.
43242.........  Uppr gi endoscopy w/  ......  T             0141      8.3175      511.26      143.38      102.25
                 us fn bx.
43243.........  Upper gi endoscopy &  ......  T             0141      8.3175      511.26      143.38      102.25
                 inject.
43244.........  Upper GI endoscopy/   ......  T             0141      8.3175      511.26      143.38      102.25
                 ligation.
43245.........  Uppr gi scope dilate  ......  T             0141      8.3175      511.26      143.38      102.25
                 strictr.
43246.........  Place gastrostomy     ......  T             0141      8.3175      511.26      143.38      102.25
                 tube.
43247.........  Operative upper GI    ......  T             0141      8.3175      511.26      143.38      102.25
                 endoscopy.
43248.........  Uppr gi endoscopy/    ......  T             0141      8.3175      511.26      143.38      102.25
                 guide wire.
43249.........  Esoph endoscopy,      ......  T             0141      8.3175      511.26      143.38      102.25
                 dilation.
43250.........  Upper GI endoscopy/   ......  T             0141      8.3175      511.26      143.38      102.25
                 tumor.
43251.........  Operative upper GI    ......  T             0141      8.3175      511.26      143.38      102.25
                 endoscopy.
43255.........  Operative upper GI    ......  T             0141      8.3175      511.26      143.38      102.25
                 endoscopy.
43256.........  Uppr gi endoscopy w/  ......  T             0384     22.9475    1,410.54      295.41      282.11
                 stent.
43257.........  Uppr gi scope w/      ......  T             0422     25.7552    1,583.12      448.81      316.62
                 thrml txmnt.
43258.........  Operative upper GI    ......  T             0141      8.3175      511.26      143.38      102.25
                 endoscopy.
43259.........  Endoscopic            ......  T             0141      8.3175      511.26      143.38      102.25
                 ultrasound exam.
43260.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43261.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43262.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43263.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43264.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43265.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43267.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43268.........  Endo                  ......  T             0384     22.9475    1,410.54      295.41      282.11
                 cholangiopancreatog
                 raph.
43269.........  Endo                  ......  T             0384     22.9475    1,410.54      295.41      282.11
                 cholangiopancreatog
                 raph.
43271.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43272.........  Endo                  ......  T             0151     19.8381    1,219.41      245.46      243.88
                 cholangiopancreatog
                 raph.
43280.........  Laparoscopy,          ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 fundoplasty.
43289.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 esoph.
43450.........  Dilate esophagus....  ......  T             0140      5.4566      335.41       91.40       67.08
43453.........  Dilate esophagus....  ......  T             0140      5.4566      335.41       91.40       67.08
43456.........  Dilate esophagus....  ......  T             0140      5.4566      335.41       91.40       67.08
43458.........  Dilate esophagus....  ......  T             0140      5.4566      335.41       91.40       67.08
43499.........  Esophagus surgery     ......  T             0141      8.3175      511.26      143.38      102.25
                 procedure.
43510.........  Surgical opening of   ......  T             0141      8.3175      511.26      143.38      102.25
                 stomach.
43600.........  Biopsy of stomach...  ......  T             0141      8.3175      511.26      143.38      102.25
43647.........  Lap impl electrode,    NI...  T             0130     32.1241    1,974.60      659.53      394.92
                 antrum.
43648.........  Lap revise/remv        NI...  T             0130     32.1241    1,974.60      659.53      394.92
                 eltrd antrum.
43651.........  Laparoscopy, vagus    ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 nerve.
43652.........  Laparoscopy, vagus    ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 nerve.
43653.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 gastrostomy.
43659.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 stom.
43750.........  Place gastrostomy     ......  T             0141      8.3175      511.26      143.38      102.25
                 tube.
43752.........  Nasal/orogastric w/   ......  X             0272      1.2908       79.34       31.64       15.87
                 stent.
43760.........  Change gastrostomy    ......  T             0121      2.3587      144.98       43.80       29.00
                 tube.
43761.........  Reposition            ......  T             0122        7.48      459.78  ..........       91.96
                 gastrostomy tube.
43830.........  Place gastrostomy     ......  T             0422     25.7552    1,583.12      448.81      316.62
                 tube.
43831.........  Place gastrostomy     ......  T             0141      8.3175      511.26      143.38      102.25
                 tube.
43870.........  Repair stomach        ......  T             0141      8.3175      511.26      143.38      102.25
                 opening.
43881.........  Impl/redo electrd,     NI...  C       ..........  ..........  ..........  ..........  ..........
                 antrum.
43882.........  Revise/remove          NI...  C       ..........  ..........  ..........  ..........  ..........
                 electrd antrum.
43886.........  Revise gastric port,  ......  T             0025      5.2594      323.28      101.85       64.66
                 open.
43887.........  Remove gastric port,  ......  T             0025      5.2594      323.28      101.85       64.66
                 open.
43888.........  Change gastric port,  ......  T             0686     14.0346      862.68  ..........      172.54
                 open.
43999.........  Stomach surgery       ......  T             0141      8.3175      511.26      143.38      102.25
                 procedure.
44100.........  Biopsy of bowel.....  ......  T             0141      8.3175      511.26      143.38      102.25
44152.........  Removal of colon/      CH...  D       ..........  ..........  ..........  ..........  ..........
                 ileostomy.
44153.........  Removal of colon/      CH...  D       ..........  ..........  ..........  ..........  ..........
                 ileostomy.
44157.........  Colectomy w/ileoanal   NI...  C       ..........  ..........  ..........  ..........  ..........
                 anast.
44158.........  Colectomy w/neo-       NI...  C       ..........  ..........  ..........  ..........  ..........
                 rectum pouch.
44180.........  Lap, enterolysis....  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
44186.........  Lap, jejunostomy....  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
44206.........  Lap part colectomy w/ ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 stoma.
44207.........  Lcolectomy/           ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 coloproctostomy.
44208.........  Lcolectomy/           ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 coloproctostomy.
44213.........  Lap, mobil splenic    ......  T             0130     32.1241    1,974.60      659.53      394.92
                 fl add-on.
44238.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 intestine.

[[Page 68322]]

 
44312.........  Revision of           ......  T             0027     21.4302    1,317.27      329.72      263.45
                 ileostomy.
44340.........  Revision of           ......  T             0027     21.4302    1,317.27      329.72      263.45
                 colostomy.
44360.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44361.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy/biopsy.
44363.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44364.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44365.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44366.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44369.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44370.........  Small bowel           ......  T             0384     22.9475    1,410.54      295.41      282.11
                 endoscopy/stent.
44372.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44373.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44376.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44377.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy/biopsy.
44378.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44379.........  Sbowel endoscope w/   ......  T             0384     22.9475    1,410.54      295.41      282.11
                 stent.
44380.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44382.........  Small bowel           ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
44383.........  Ileoscopy w/stent...  ......  T             0384     22.9475    1,410.54      295.41      282.11
44385.........  Endoscopy of bowel    ......  T             0143      8.7686      538.99      186.06      107.80
                 pouch.
44386.........  Endoscopy, bowel      ......  T             0143      8.7686      538.99      186.06      107.80
                 pouch/biop.
44388.........  Colonoscopy.........  ......  T             0143      8.7686      538.99      186.06      107.80
44389.........  Colonoscopy with      ......  T             0143      8.7686      538.99      186.06      107.80
                 biopsy.
44390.........  Colonoscopy for       ......  T             0143      8.7686      538.99      186.06      107.80
                 foreign body.
44391.........  Colonoscopy for       ......  T             0143      8.7686      538.99      186.06      107.80
                 bleeding.
44392.........  Colonoscopy &         ......  T             0143      8.7686      538.99      186.06      107.80
                 polypectomy.
44393.........  Colonoscopy, lesion   ......  T             0143      8.7686      538.99      186.06      107.80
                 removal.
44394.........  Colonoscopy w/snare.  ......  T             0143      8.7686      538.99      186.06      107.80
44397.........  Colonoscopy w/stent.  ......  T             0384     22.9475    1,410.54      295.41      282.11
44500.........  Intro,                ......  T             0121      2.3587      144.98       43.80       29.00
                 gastrointestinal
                 tube.
44701.........  Intraop colon lavage  ......  N       ..........  ..........  ..........  ..........  ..........
                 add-on.
44799.........  Unlisted procedure     CH...  T             0153     22.0832    1,357.41      397.95      271.48
                 intestine.
44901.........  Drain app abscess,    ......  T             0037     10.2655      631.00      228.76      126.20
                 percut.
44970.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 appendectomy.
44979.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 app.
45000.........  Drainage of pelvic    ......  T             0148       5.077      312.07  ..........       62.41
                 abscess.
45005.........  Drainage of rectal    ......  T             0155     12.7389      783.03  ..........      156.61
                 abscess.
45020.........  Drainage of rectal    ......  T             0155     12.7389      783.03  ..........      156.61
                 abscess.
45100.........  Biopsy of rectum....  ......  T             0149     22.2682    1,368.78      293.06      273.76
45108.........  Removal of anorectal   CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 lesion.
45150.........  Excision of rectal    ......  T             0149     22.2682    1,368.78      293.06      273.76
                 stricture.
45160.........  Excision of rectal     CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 lesion.
45170.........  Excision of rectal     CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 lesion.
45190.........  Destruction, rectal    CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 tumor.
45300.........  Proctosigmoidoscopy   ......  T             0146      4.8683      299.24       64.40       59.85
                 dx.
45303.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 dilate.
45305.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 w/bx.
45307.........  Proctosigmoidoscopy   ......  T             0428     20.6375    1,268.55  ..........      253.71
                 fb.
45308.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 removal.
45309.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 removal.
45315.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 removal.
45317.........  Proctosigmoidoscopy   ......  T             0147      8.5477      525.41  ..........      105.08
                 bleed.
45320.........  Proctosigmoidoscopy   ......  T             0428     20.6375    1,268.55  ..........      253.71
                 ablate.
45321.........  Proctosigmoidoscopy   ......  T             0428     20.6375    1,268.55  ..........      253.71
                 volvul.
45327.........  Proctosigmoidoscopy   ......  T             0384     22.9475    1,410.54      295.41      282.11
                 w/stent.
45330.........  Diagnostic            ......  T             0146      4.8683      299.24       64.40       59.85
                 sigmoidoscopy.
45331.........  Sigmoidoscopy and     ......  T             0146      4.8683      299.24       64.40       59.85
                 biopsy.
45332.........  Sigmoidoscopy w/fb    ......  T             0146      4.8683      299.24       64.40       59.85
                 removal.
45333.........  Sigmoidoscopy &       ......  T             0147      8.5477      525.41  ..........      105.08
                 polypectomy.
45334.........  Sigmoidoscopy for     ......  T             0147      8.5477      525.41  ..........      105.08
                 bleeding.
45335.........  Sigmoidoscopy w/      ......  T             0146      4.8683      299.24       64.40       59.85
                 submuc inj.
45337.........  Sigmoidoscopy &       ......  T             0146      4.8683      299.24       64.40       59.85
                 decompress.
45338.........  Sigmoidoscopy w/tumr  ......  T             0147      8.5477      525.41  ..........      105.08
                 remove.
45339.........  Sigmoidoscopy w/      ......  T             0147      8.5477      525.41  ..........      105.08
                 ablate tumr.
45340.........  Sig w/balloon         ......  T             0147      8.5477      525.41  ..........      105.08
                 dilation.
45341.........  Sigmoidoscopy w/      ......  T             0147      8.5477      525.41  ..........      105.08
                 ultrasound.
45342.........  Sigmoidoscopy w/us    ......  T             0147      8.5477      525.41  ..........      105.08
                 guide bx.
45345.........  Sigmoidoscopy w/      ......  T             0384     22.9475    1,410.54      295.41      282.11
                 stent.
45355.........  Surgical colonoscopy  ......  T             0143      8.7686      538.99      186.06      107.80
45378.........  Diagnostic            ......  T             0143      8.7686      538.99      186.06      107.80
                 colonoscopy.

[[Page 68323]]

 
45379.........  Colonoscopy w/fb      ......  T             0143      8.7686      538.99      186.06      107.80
                 removal.
45380.........  Colonoscopy and       ......  T             0143      8.7686      538.99      186.06      107.80
                 biopsy.
45381.........  Colonoscopy,          ......  T             0143      8.7686      538.99      186.06      107.80
                 submucous inj.
45382.........  Colonoscopy/control   ......  T             0143      8.7686      538.99      186.06      107.80
                 bleeding.
45383.........  Lesion removal        ......  T             0143      8.7686      538.99      186.06      107.80
                 colonoscopy.
45384.........  Lesion remove         ......  T             0143      8.7686      538.99      186.06      107.80
                 colonoscopy.
45385.........  Lesion removal        ......  T             0143      8.7686      538.99      186.06      107.80
                 colonoscopy.
45386.........  Colonoscopy dilate    ......  T             0143      8.7686      538.99      186.06      107.80
                 stricture.
45387.........  Colonoscopy w/stent.  ......  T             0384     22.9475    1,410.54      295.41      282.11
45391.........  Colonoscopy w/        ......  T             0143      8.7686      538.99      186.06      107.80
                 endoscope us.
45392.........  Colonoscopy w/        ......  T             0143      8.7686      538.99      186.06      107.80
                 endoscopic fnb.
45499.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 rectum.
45500.........  Repair of rectum....  ......  T             0149     22.2682    1,368.78      293.06      273.76
45505.........  Repair of rectum....  ......  T             0150     29.6189    1,820.61      437.12      364.12
45520.........  Treatment of rectal   ......  T             0098      1.0798       66.37  ..........       13.27
                 prolapse.
45541.........  Correct rectal        ......  T             0150     29.6189    1,820.61      437.12      364.12
                 prolapse.
45560.........  Repair of rectocele.  ......  T             0150     29.6189    1,820.61      437.12      364.12
45900.........  Reduction of rectal   ......  T             0148       5.077      312.07  ..........       62.41
                 prolapse.
45905.........  Dilation of anal      ......  T             0149     22.2682    1,368.78      293.06      273.76
                 sphincter.
45910.........  Dilation of rectal    ......  T             0149     22.2682    1,368.78      293.06      273.76
                 narrowing.
45915.........  Remove rectal         ......  T             0148       5.077      312.07  ..........       62.41
                 obstruction.
45990.........  Surg dx exam,         ......  T             0148       5.077      312.07  ..........       62.41
                 anorectal.
45999.........  Rectum surgery        ......  T             0148       5.077      312.07  ..........       62.41
                 procedure.
46020.........  Placement of seton..   CH...  T             0149     22.2682    1,368.78      293.06      273.76
46030.........  Removal of rectal     ......  T             0148       5.077      312.07  ..........       62.41
                 marker.
46040.........  Incision of rectal    ......  T             0149     22.2682    1,368.78      293.06      273.76
                 abscess.
46045.........  Incision of rectal     CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 abscess.
46050.........  Incision of anal      ......  T             0148       5.077      312.07  ..........       62.41
                 abscess.
46060.........  Incision of rectal     CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 abscess.
46070.........  Incision of anal      ......  T             0155     12.7389      783.03  ..........      156.61
                 septum.
46080.........  Incision of anal      ......  T             0149     22.2682    1,368.78      293.06      273.76
                 sphincter.
46083.........  Incise external        CH...  T             0164      2.1393      131.50  ..........       26.30
                 hemorrhoid.
46200.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fissure.
46210.........  Removal of anal       ......  T             0149     22.2682    1,368.78      293.06      273.76
                 crypt.
46211.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 crypts.
46220.........  Removal of anal tag.  ......  T             0149     22.2682    1,368.78      293.06      273.76
46221.........  Ligation of           ......  T             0148       5.077      312.07  ..........       62.41
                 hemorrhoid(s).
46230.........  Removal of anal tags  ......  T             0149     22.2682    1,368.78      293.06      273.76
46250.........  Hemorrhoidectomy....   CH...  T             0149     22.2682    1,368.78      293.06      273.76
46255.........  Hemorrhoidectomy....   CH...  T             0149     22.2682    1,368.78      293.06      273.76
46257.........  Remove hemorrhoids &   CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fissure.
46258.........  Remove hemorrhoids &   CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46260.........  Hemorrhoidectomy....   CH...  T             0149     22.2682    1,368.78      293.06      273.76
46261.........  Remove hemorrhoids &   CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fissure.
46262.........  Remove hemorrhoids &   CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46270.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46275.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46280.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46285.........  Removal of anal        CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 fistula.
46288.........  Repair anal fistula.   CH...  T             0149     22.2682    1,368.78      293.06      273.76
46320.........  Removal of             CH...  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoid clot.
46500.........  Injection into        ......  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoid(s).
46505.........  Chemodenervation      ......  T             0148       5.077      312.07  ..........       62.41
                 anal musc.
46600.........  Diagnostic anoscopy.  ......  X             0340      0.6102       37.51  ..........        7.50
46604.........  Anoscopy and          ......  T             0147      8.5477      525.41  ..........      105.08
                 dilation.
46606.........  Anoscopy and biopsy.  ......  T             0146      4.8683      299.24       64.40       59.85
46608.........  Anoscopy, remove for  ......  T             0147      8.5477      525.41  ..........      105.08
                 body.
46610.........  Anoscopy, remove      ......  T             0428     20.6375    1,268.55  ..........      253.71
                 lesion.
46611.........  Anoscopy............  ......  T             0147      8.5477      525.41  ..........      105.08
46612.........  Anoscopy, remove      ......  T             0428     20.6375    1,268.55  ..........      253.71
                 lesions.
46614.........  Anoscopy, control     ......  T             0146      4.8683      299.24       64.40       59.85
                 bleeding.
46615.........  Anoscopy............  ......  T             0428     20.6375    1,268.55  ..........      253.71
46700.........  Repair of anal         CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 stricture.
46706.........  Repr of anal fistula  ......  T             0150     29.6189    1,820.61      437.12      364.12
                 w/glue.
46750.........  Repair of anal         CH...  T             0171     37.8991    2,329.58      716.76      465.92
                 sphincter.
46753.........  Reconstruction of      CH...  T             0149     22.2682    1,368.78      293.06      273.76
                 anus.
46754.........  Removal of suture     ......  T             0149     22.2682    1,368.78      293.06      273.76
                 from anus.
46760.........  Repair of anal         CH...  T             0171     37.8991    2,329.58      716.76      465.92
                 sphincter.
46761.........  Repair of anal         CH...  T             0171     37.8991    2,329.58      716.76      465.92
                 sphincter.
46762.........  Implant artificial     CH...  T             0171     37.8991    2,329.58      716.76      465.92
                 sphincter.

[[Page 68324]]

 
46900.........  Destruction, anal     ......  T             0016      2.6749      164.42  ..........       32.88
                 lesion(s).
46910.........  Destruction, anal     ......  T             0017     17.4423    1,072.14      227.84      214.43
                 lesion(s).
46916.........  Cryosurgery, anal     ......  T             0013      1.0918       67.11  ..........       13.42
                 lesion(s).
46917.........  Laser surgery, anal   ......  T             0695     20.4276    1,255.64      266.59      251.13
                 lesions.
46922.........  Excision of anal      ......  T             0695     20.4276    1,255.64      266.59      251.13
                 lesion(s).
46924.........  Destruction, anal     ......  T             0695     20.4276    1,255.64      266.59      251.13
                 lesion(s).
46934.........  Destruction of        ......  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoids.
46935.........  Destruction of        ......  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoids.
46936.........  Destruction of        ......  T             0149     22.2682    1,368.78      293.06      273.76
                 hemorrhoids.
46937.........  Cryotherapy of        ......  T             0149     22.2682    1,368.78      293.06      273.76
                 rectal lesion.
46938.........  Cryotherapy of        ......  T             0150     29.6189    1,820.61      437.12      364.12
                 rectal lesion.
46940.........  Treatment of anal     ......  T             0149     22.2682    1,368.78      293.06      273.76
                 fissure.
46942.........  Treatment of anal     ......  T             0148       5.077      312.07  ..........       62.41
                 fissure.
46945.........  Ligation of           ......  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoids.
46946.........  Ligation of           ......  T             0155     12.7389      783.03  ..........      156.61
                 hemorrhoids.
46947.........  Hemorrhoidopexy by    ......  T             0150     29.6189    1,820.61      437.12      364.12
                 stapling.
46999.........  Anus surgery          ......  T             0148       5.077      312.07  ..........       62.41
                 procedure.
47000.........  Needle biopsy of      ......  T             0685      6.1384      377.32      115.47       75.46
                 liver.
47001.........  Needle biopsy, liver  ......  N       ..........  ..........  ..........  ..........  ..........
                 add-on.
47011.........  Percut drain, liver   ......  T             0037     10.2655      631.00      228.76      126.20
                 lesion.
47370.........  Laparo ablate liver   ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 tumor rf.
47371.........  Laparo ablate liver   ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 cryosurg.
47379.........  Laparoscope           ......  T             0130     32.1241    1,974.60      659.53      394.92
                 procedure, liver.
47382.........  Percut ablate liver   ......  T             0423     37.3604    2,296.47  ..........      459.29
                 rf.
47399.........  Liver surgery          CH...  T             0004      2.0687      127.16  ..........       25.43
                 procedure.
47490.........  Incision of           ......  T             0152     20.2682    1,245.85  ..........      249.17
                 gallbladder.
47500.........  Injection for liver   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-rays.
47505.........  Injection for liver   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-rays.
47510.........  Insert catheter,      ......  T             0152     20.2682    1,245.85  ..........      249.17
                 bile duct.
47511.........  Insert bile duct      ......  T             0152     20.2682    1,245.85  ..........      249.17
                 drain.
47525.........  Change bile duct      ......  T             0427     11.6575      716.56  ..........      143.31
                 catheter.
47530.........  Revise/reinsert bile  ......  T             0427     11.6575      716.56  ..........      143.31
                 tube.
47552.........  Biliary endoscopy     ......  T             0152     20.2682    1,245.85  ..........      249.17
                 thru skin.
47553.........  Biliary endoscopy     ......  T             0152     20.2682    1,245.85  ..........      249.17
                 thru skin.
47554.........  Biliary endoscopy     ......  T             0152     20.2682    1,245.85  ..........      249.17
                 thru skin.
47555.........  Biliary endoscopy     ......  T             0152     20.2682    1,245.85  ..........      249.17
                 thru skin.
47556.........  Biliary endoscopy     ......  T             0152     20.2682    1,245.85  ..........      249.17
                 thru skin.
47560.........  Laparoscopy w/        ......  T             0130     32.1241    1,974.60      659.53      394.92
                 cholangio.
47561.........  Laparo w/cholangio/   ......  T             0130     32.1241    1,974.60      659.53      394.92
                 biopsy.
47562.........  Laparoscopic          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 cholecystectomy.
47563.........  Laparo                ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 cholecystectomy/
                 graph.
47564.........  Laparo                ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 cholecystectomy/
                 explr.
47579.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 biliary.
47630.........  Remove bile duct      ......  T             0152     20.2682    1,245.85  ..........      249.17
                 stone.
47716.........  Fusion of bile duct    CH...  D       ..........  ..........  ..........  ..........  ..........
                 cyst.
47719.........  Fusion of bile duct    NI...  C       ..........  ..........  ..........  ..........  ..........
                 cyst.
47999.........  Bile tract surgery    ......  T             0152     20.2682    1,245.85  ..........      249.17
                 procedure.
48005.........  Resect/debride         CH...  D       ..........  ..........  ..........  ..........  ..........
                 pancreas.
48102.........  Needle biopsy,        ......  T             0685      6.1384      377.32      115.47       75.46
                 pancreas.
48105.........  Resect/debride         NI...  C       ..........  ..........  ..........  ..........  ..........
                 pancreas.
48180.........  Fuse pancreas and      CH...  D       ..........  ..........  ..........  ..........  ..........
                 bowel.
48511.........  Drain pancreatic      ......  T             0037     10.2655      631.00      228.76      126.20
                 pseudocyst.
48548.........  Fuse pancreas and      NI...  C       ..........  ..........  ..........  ..........  ..........
                 bowel.
48999.........  Pancreas surgery      ......  T             0004      2.0687      127.16  ..........       25.43
                 procedure.
49021.........  Drain abdominal       ......  T             0037     10.2655      631.00      228.76      126.20
                 abscess.
49041.........  Drain, percut, abdom  ......  T             0037     10.2655      631.00      228.76      126.20
                 abscess.
49061.........  Drain, percut,        ......  T             0037     10.2655      631.00      228.76      126.20
                 retroper absc.
49080.........  Puncture, peritoneal  ......  T             0070      3.6244      222.78  ..........       44.56
                 cavity.
49081.........  Removal of abdominal  ......  T             0070      3.6244      222.78  ..........       44.56
                 fluid.
49085.........  Remove abdomen         CH...  D       ..........  ..........  ..........  ..........  ..........
                 foreign body.
49180.........  Biopsy, abdominal     ......  T             0685      6.1384      377.32      115.47       75.46
                 mass.
49200.........  Removal of abdominal  ......  T             0130     32.1241    1,974.60      659.53      394.92
                 lesion.
49250.........  Excision of           ......  T             0153     22.0832    1,357.41      397.95      271.48
                 umbilicus.
49320.........  Diag laparo separate  ......  T             0130     32.1241    1,974.60      659.53      394.92
                 proc.
49321.........  Laparoscopy, biopsy.  ......  T             0130     32.1241    1,974.60      659.53      394.92
49322.........  Laparoscopy,          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 aspiration.
49323.........  Laparo drain          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 lymphocele.
49324.........  Lap insertion perm     NI...  T             0130     32.1241    1,974.60      659.53      394.92
                 ip cath.
49325.........  Lap revision perm ip   NI...  T             0130     32.1241    1,974.60      659.53      394.92
                 cath.
49326.........  Lap w/omentopexy add-  NI...  T             0130     32.1241    1,974.60      659.53      394.92
                 on.

[[Page 68325]]

 
49329.........  Laparo proc, abdm/    ......  T             0130     32.1241    1,974.60      659.53      394.92
                 per/oment.
49400.........  Air injection into    ......  N       ..........  ..........  ..........  ..........  ..........
                 abdomen.
49402.........  Remove foreign body,   NI...  T             0153     22.0832    1,357.41      397.95      271.48
                 adbomen.
49419.........  Insrt abdom cath for  ......  T             0115     29.2133    1,795.68      374.81      359.14
                 chemotx.
49420.........  Insert abdom drain,   ......  T             0652     29.5416    1,815.86  ..........      363.17
                 temp.
49421.........  Insert abdom drain,   ......  T             0652     29.5416    1,815.86  ..........      363.17
                 perm.
49422.........  Remove perm cannula/  ......  T             0105     25.6142    1,574.45      370.40      314.89
                 catheter.
49423.........  Exchange drainage     ......  T             0427     11.6575      716.56  ..........      143.31
                 catheter.
49424.........  Assess cyst,          ......  N       ..........  ..........  ..........  ..........  ..........
                 contrast inject.
49426.........  Revise abdomen-       ......  T             0153     22.0832    1,357.41      397.95      271.48
                 venous shunt.
49427.........  Injection, abdominal  ......  N       ..........  ..........  ..........  ..........  ..........
                 shunt.
49429.........  Removal of shunt....  ......  T             0105     25.6142    1,574.45      370.40      314.89
49435.........  Insert subq exten to   NI...  T             0427     11.6575      716.56  ..........      143.31
                 ip cath.
49436.........  Embedded ip cath       NI...  T             0427     11.6575      716.56  ..........      143.31
                 exit-site.
49491.........  Rpr hern preemie      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduc.
49492.........  Rpr ing hern premie,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49495.........  Rpr ing hernia baby,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduc.
49496.........  Rpr ing hernia baby,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49500.........  Rpr ing hernia,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 init, reduce.
49501.........  Rpr ing hernia, init  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49505.........  Prp i/hern init       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduc >5 yr.
49507.........  Prp i/hern init       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 block >5 yr.
49520.........  Rerepair ing hernia,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduce.
49521.........  Rerepair ing hernia,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49525.........  Repair ing hernia,    ......  T             0154     29.2182    1,795.98      464.85      359.20
                 sliding.
49540.........  Repair lumbar hernia  ......  T             0154     29.2182    1,795.98      464.85      359.20
49550.........  Rpr rem hernia,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 init, reduce.
49553.........  Rpr fem hernia, init  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49555.........  Rerepair fem hernia,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduce.
49557.........  Rerepair fem hernia,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49560.........  Rpr ventral hern      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 init, reduc.
49561.........  Rpr ventral hern      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 init, block.
49565.........  Rerepair ventrl       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 hern, reduce.
49566.........  Rerepair ventrl       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 hern, block.
49568.........  Hernia repair w/mesh  ......  T             0154     29.2182    1,795.98      464.85      359.20
49570.........  Rpr epigastric hern,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduce.
49572.........  Rpr epigastric hern,  ......  T             0154     29.2182    1,795.98      464.85      359.20
                 blocked.
49580.........  Rpr umbil hern,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduc < 5 yr.
49582.........  Rpr umbil hern,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 block < 5 yr.
49585.........  Rpr umbil hern,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 reduc > 5 yr.
49587.........  Rpr umbil hern,       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 block > 5 yr.
49590.........  Repair spigelian      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 hernia.
49600.........  Repair umbilical      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 lesion.
49650.........  Laparo hernia repair  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 initial.
49651.........  Laparo hernia repair  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 recur.
49659.........  Laparo proc, hernia   ......  T             0130     32.1241    1,974.60      659.53      394.92
                 repair.
49999.........  Abdomen surgery       ......  T             0153     22.0832    1,357.41      397.95      271.48
                 procedure.
50020.........  Renal abscess, open   ......  T             0162       23.87    1,467.24  ..........      293.45
                 drain.
50021.........  Renal abscess,        ......  T             0037     10.2655      631.00      228.76      126.20
                 percut drain.
50080.........  Removal of kidney     ......  T             0429     43.1004    2,649.30  ..........      529.86
                 stone.
50081.........  Removal of kidney     ......  T             0429     43.1004    2,649.30  ..........      529.86
                 stone.
50200.........  Biopsy of kidney....  ......  T             0685      6.1384      377.32      115.47       75.46
50382.........  Change ureter stent,  ......  T             0161     19.2251    1,181.73      249.36      236.35
                 percut.
50384.........  Remove ureter stent,  ......  T             0161     19.2251    1,181.73      249.36      236.35
                 percut.
50387.........  Change ext/int        ......  T             0122        7.48      459.78  ..........       91.96
                 ureter stent.
50389.........  Remove renal tube w/  ......  T             0156      3.4079      209.48  ..........       41.90
                 fluoro.
50390.........  Drainage of kidney    ......  T             0685      6.1384      377.32      115.47       75.46
                 lesion.
50391.........  Instll rx agnt into    CH...  T             0126      1.0887       66.92       16.45       13.38
                 rnal tub.
50392.........  Insert kidney drain.  ......  T             0161     19.2251    1,181.73      249.36      236.35
50393.........  Insert ureteral tube  ......  T             0161     19.2251    1,181.73      249.36      236.35
50394.........  Injection for kidney  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
50395.........  Create passage to     ......  T             0161     19.2251    1,181.73      249.36      236.35
                 kidney.
50396.........  Measure kidney        ......  T             0164      2.1393      131.50  ..........       26.30
                 pressure.
50398.........  Change kidney tube..  ......  T             0122        7.48      459.78  ..........       91.96
50541.........  Laparo ablate renal   ......  T             0130     32.1241    1,974.60      659.53      394.92
                 cyst.
50542.........  Laparo ablate renal   ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 mass.
50543.........  Laparo partial        ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 nephrectomy.
50544.........  Laparoscopy,          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 pyeloplasty.
50549.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 renal.
50551.........  Kidney endoscopy....  ......  T             0160      6.4951      399.24      101.58       79.85

[[Page 68326]]

 
50553.........  Kidney endoscopy....  ......  T             0161     19.2251    1,181.73      249.36      236.35
50555.........  Kidney endoscopy &    ......  T             0160      6.4951      399.24      101.58       79.85
                 biopsy.
50557.........  Kidney endoscopy &    ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
50561.........  Kidney endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
50562.........  Renal scope w/tumor   ......  T             0160      6.4951      399.24      101.58       79.85
                 resect.
50570.........  Kidney endoscopy....  ......  T             0160      6.4951      399.24      101.58       79.85
50572.........  Kidney endoscopy....  ......  T             0160      6.4951      399.24      101.58       79.85
50574.........  Kidney endoscopy &    ......  T             0160      6.4951      399.24      101.58       79.85
                 biopsy.
50575.........  Kidney endoscopy....  ......  T             0163     34.9261    2,146.84  ..........      429.37
50576.........  Kidney endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
50590.........  Fragmenting of        ......  T             0169     43.5398    2,676.30    1,009.47      535.26
                 kidney stone.
50592.........  Perc rf ablate renal  ......  T             0423     37.3604    2,296.47  ..........      459.29
                 tumor.
50684.........  Injection for ureter  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
50686.........  Measure ureter         CH...  T             0126      1.0887       66.92       16.45       13.38
                 pressure.
50688.........  Change of ureter      ......  T             0122        7.48      459.78  ..........       91.96
                 tube/stent.
50690.........  Injection for ureter  ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
50945.........  Laparoscopy           ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 ureterolithotomy.
50947.........  Laparo new ureter/    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 bladder.
50948.........  Laparo new ureter/    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 bladder.
50949.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 ureter.
50951.........  Endoscopy of ureter.  ......  T             0160      6.4951      399.24      101.58       79.85
50953.........  Endoscopy of ureter.  ......  T             0160      6.4951      399.24      101.58       79.85
50955.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 biopsy.
50957.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
50961.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
50970.........  Ureter endoscopy....  ......  T             0160      6.4951      399.24      101.58       79.85
50972.........  Ureter endoscopy &    ......  T             0160      6.4951      399.24      101.58       79.85
                 catheter.
50974.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 biopsy.
50976.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
50980.........  Ureter endoscopy &    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
51000.........  Drainage of bladder.  ......  T             0164      2.1393      131.50  ..........       26.30
51005.........  Drainage of bladder.   CH...  T             0126      1.0887       66.92       16.45       13.38
51010.........  Drainage of bladder.  ......  T             0165     18.1679    1,116.74  ..........      223.35
51020.........  Incise & treat        ......  T             0162       23.87    1,467.24  ..........      293.45
                 bladder.
51030.........  Incise & treat        ......  T             0162       23.87    1,467.24  ..........      293.45
                 bladder.
51040.........  Incise & drain        ......  T             0162       23.87    1,467.24  ..........      293.45
                 bladder.
51045.........  Incise bladder/drain  ......  T             0160      6.4951      399.24      101.58       79.85
                 ureter.
51050.........  Removal of bladder    ......  T             0162       23.87    1,467.24  ..........      293.45
                 stone.
51065.........  Remove ureter         ......  T             0162       23.87    1,467.24  ..........      293.45
                 calculus.
51080.........  Drainage of bladder   ......  T             0008     17.5086    1,076.22  ..........      215.24
                 abscess.
51500.........  Removal of bladder    ......  T             0154     29.2182    1,795.98      464.85      359.20
                 cyst.
51520.........  Removal of bladder    ......  T             0162       23.87    1,467.24  ..........      293.45
                 lesion.
51600.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 bladder x-ray.
51605.........  Preparation for       ......  N       ..........  ..........  ..........  ..........  ..........
                 bladder xray.
51610.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 bladder x-ray.
51700.........  Irrigation of         ......  T             0164      2.1393      131.50  ..........       26.30
                 bladder.
51701.........  Insert bladder        ......  X             0340      0.6102       37.51  ..........        7.50
                 catheter.
51702.........  Insert temp bladder   ......  X             0340      0.6102       37.51  ..........        7.50
                 cath.
51703.........  Insert bladder cath,   CH...  T             0126      1.0887       66.92       16.45       13.38
                 complex.
51705.........  Change of bladder     ......  T             0121      2.3587      144.98       43.80       29.00
                 tube.
51710.........  Change of bladder     ......  T             0122        7.48      459.78  ..........       91.96
                 tube.
51715.........  Endoscopic injection/ ......  T             0168     29.0253    1,784.13      388.16      356.83
                 implant.
51720.........  Treatment of bladder   CH...  T             0164      2.1393      131.50  ..........       26.30
                 lesion.
51725.........  Simple                 CH...  T             0164      2.1393      131.50  ..........       26.30
                 cystometrogram.
51726.........  Complex               ......  T             0156      3.4079      209.48  ..........       41.90
                 cystometrogram.
51736.........  Urine flow             CH...  T             0126      1.0887       66.92       16.45       13.38
                 measurement.
51741.........  Electro-               CH...  T             0126      1.0887       66.92       16.45       13.38
                 uroflowmetry, first.
51772.........  Urethra pressure       CH...  T             0164      2.1393      131.50  ..........       26.30
                 profile.
51784.........  Anal/urinary muscle    CH...  T             0126      1.0887       66.92       16.45       13.38
                 study.
51785.........  Anal/urinary muscle    CH...  T             0126      1.0887       66.92       16.45       13.38
                 study.
51792.........  Urinary reflex study   CH...  T             0126      1.0887       66.92       16.45       13.38
51795.........  Urine voiding         ......  T             0164      2.1393      131.50  ..........       26.30
                 pressure study.
51797.........  Intraabdominal        ......  T             0164      2.1393      131.50  ..........       26.30
                 pressure test.
51798.........  Us urine capacity     ......  X             0340      0.6102       37.51  ..........        7.50
                 measure.
51880.........  Repair of bladder     ......  T             0162       23.87    1,467.24  ..........      293.45
                 opening.
51990.........  Laparo urethral       ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 suspension.
51992.........  Laparo sling           CH...  T             0131     43.5488    2,676.86    1,001.89      535.37
                 operation.
51999.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 bladder.
52000.........  Cystoscopy..........  ......  T             0160      6.4951      399.24      101.58       79.85
52001.........  Cystoscopy, removal   ......  T             0160      6.4951      399.24      101.58       79.85
                 of clots.

[[Page 68327]]

 
52005.........  Cystoscopy & ureter   ......  T             0161     19.2251    1,181.73      249.36      236.35
                 catheter.
52007.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 biopsy.
52010.........  Cystoscopy & duct     ......  T             0160      6.4951      399.24      101.58       79.85
                 catheter.
52204.........  Cystoscopy w/         ......  T             0161     19.2251    1,181.73      249.36      236.35
                 biopsy(s).
52214.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52224.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52234.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52235.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52240.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52250.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 radiotracer.
52260.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52265.........  Cystoscopy and        ......  T             0160      6.4951      399.24      101.58       79.85
                 treatment.
52270.........  Cystoscopy & revise   ......  T             0161     19.2251    1,181.73      249.36      236.35
                 urethra.
52275.........  Cystoscopy & revise   ......  T             0161     19.2251    1,181.73      249.36      236.35
                 urethra.
52276.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52277.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52281.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52282.........  Cystoscopy, implant   ......  T             0163     34.9261    2,146.84  ..........      429.37
                 stent.
52283.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52285.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52290.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52300.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52301.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52305.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52310.........  Cystoscopy and        ......  T             0160      6.4951      399.24      101.58       79.85
                 treatment.
52315.........  Cystoscopy and        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 treatment.
52317.........  Remove bladder stone  ......  T             0162       23.87    1,467.24  ..........      293.45
52318.........  Remove bladder stone  ......  T             0162       23.87    1,467.24  ..........      293.45
52320.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52325.........  Cystoscopy, stone     ......  T             0162       23.87    1,467.24  ..........      293.45
                 removal.
52327.........  Cystoscopy, inject    ......  T             0162       23.87    1,467.24  ..........      293.45
                 material.
52330.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52332.........  Cystoscopy and        ......  T             0162       23.87    1,467.24  ..........      293.45
                 treatment.
52334.........  Create passage to     ......  T             0162       23.87    1,467.24  ..........      293.45
                 kidney.
52341.........  Cysto w/ureter        ......  T             0162       23.87    1,467.24  ..........      293.45
                 stricture tx.
52342.........  Cysto w/up stricture  ......  T             0162       23.87    1,467.24  ..........      293.45
                 tx.
52343.........  Cysto w/renal         ......  T             0162       23.87    1,467.24  ..........      293.45
                 stricture tx.
52344.........  Cysto/uretero,        ......  T             0162       23.87    1,467.24  ..........      293.45
                 stricture tx.
52345.........  Cysto/uretero w/up    ......  T             0162       23.87    1,467.24  ..........      293.45
                 stricture.
52346.........  Cystouretero w/renal  ......  T             0162       23.87    1,467.24  ..........      293.45
                 strict.
52351.........  Cystouretero & or     ......  T             0161     19.2251    1,181.73      249.36      236.35
                 pyeloscope.
52352.........  Cystouretero w/stone  ......  T             0162       23.87    1,467.24  ..........      293.45
                 remove.
52353.........  Cystouretero w/       ......  T             0163     34.9261    2,146.84  ..........      429.37
                 lithotripsy.
52354.........  Cystouretero w/       ......  T             0162       23.87    1,467.24  ..........      293.45
                 biopsy.
52355.........  Cystouretero w/       ......  T             0162       23.87    1,467.24  ..........      293.45
                 excise tumor.
52400.........  Cystouretero w/       ......  T             0162       23.87    1,467.24  ..........      293.45
                 congen repr.
52402.........  Cystourethro cut      ......  T             0162       23.87    1,467.24  ..........      293.45
                 ejacul duct.
52450.........  Incision of prostate  ......  T             0162       23.87    1,467.24  ..........      293.45
52500.........  Revision of bladder   ......  T             0162       23.87    1,467.24  ..........      293.45
                 neck.
52510.........  Dilation prostatic    ......  T             0161     19.2251    1,181.73      249.36      236.35
                 urethra.
52601.........  Prostatectomy (TURP)  ......  T             0163     34.9261    2,146.84  ..........      429.37
52606.........  Control postop        ......  T             0162       23.87    1,467.24  ..........      293.45
                 bleeding.
52612.........  Prostatectomy, first  ......  T             0163     34.9261    2,146.84  ..........      429.37
                 stage.
52614.........  Prostatectomy,        ......  T             0163     34.9261    2,146.84  ..........      429.37
                 second stage.
52620.........  Remove residual       ......  T             0163     34.9261    2,146.84  ..........      429.37
                 prostate.
52630.........  Remove prostate       ......  T             0163     34.9261    2,146.84  ..........      429.37
                 regrowth.
52640.........  Relieve bladder       ......  T             0162       23.87    1,467.24  ..........      293.45
                 contracture.
52647.........  Laser surgery of      ......  T             0429     43.1004    2,649.30  ..........      529.86
                 prostate.
52648.........  Laser surgery of      ......  T             0429     43.1004    2,649.30  ..........      529.86
                 prostate.
52700.........  Drainage of prostate  ......  T             0162       23.87    1,467.24  ..........      293.45
                 abscess.
53000.........  Incision of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53010.........  Incision of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53020.........  Incision of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53025.........  Incision of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53040.........  Drainage of urethra   ......  T             0166      18.396    1,130.77  ..........      226.15
                 abscess.
53060.........  Drainage of urethra   ......  T             0166      18.396    1,130.77  ..........      226.15
                 abscess.
53080.........  Drainage of urinary   ......  T             0166      18.396    1,130.77  ..........      226.15
                 leakage.
53085.........  Drainage of urinary   ......  T             0166      18.396    1,130.77  ..........      226.15
                 leakage.
53200.........  Biopsy of urethra...  ......  T             0166      18.396    1,130.77  ..........      226.15
53210.........  Removal of urethra..  ......  T             0168     29.0253    1,784.13      388.16      356.83

[[Page 68328]]

 
53215.........  Removal of urethra..  ......  T             0166      18.396    1,130.77  ..........      226.15
53220.........  Treatment of urethra  ......  T             0168     29.0253    1,784.13      388.16      356.83
                 lesion.
53230.........  Removal of urethra    ......  T             0168     29.0253    1,784.13      388.16      356.83
                 lesion.
53235.........  Removal of urethra    ......  T             0166      18.396    1,130.77  ..........      226.15
                 lesion.
53240.........  Surgery for urethra   ......  T             0168     29.0253    1,784.13      388.16      356.83
                 pouch.
53250.........  Removal of urethra    ......  T             0166      18.396    1,130.77  ..........      226.15
                 gland.
53260.........  Treatment of urethra  ......  T             0166      18.396    1,130.77  ..........      226.15
                 lesion.
53265.........  Treatment of urethra  ......  T             0166      18.396    1,130.77  ..........      226.15
                 lesion.
53270.........  Removal of urethra    ......  T             0166      18.396    1,130.77  ..........      226.15
                 gland.
53275.........  Repair of urethra     ......  T             0166      18.396    1,130.77  ..........      226.15
                 defect.
53400.........  Revise urethra,       ......  T             0168     29.0253    1,784.13      388.16      356.83
                 stage 1.
53405.........  Revise urethra,       ......  T             0168     29.0253    1,784.13      388.16      356.83
                 stage 2.
53410.........  Reconstruction of     ......  T             0168     29.0253    1,784.13      388.16      356.83
                 urethra.
53420.........  Reconstruct urethra,  ......  T             0168     29.0253    1,784.13      388.16      356.83
                 stage 1.
53425.........  Reconstruct urethra,  ......  T             0168     29.0253    1,784.13      388.16      356.83
                 stage 2.
53430.........  Reconstruction of     ......  T             0168     29.0253    1,784.13      388.16      356.83
                 urethra.
53431.........  Reconstruct urethra/  ......  T             0168     29.0253    1,784.13      388.16      356.83
                 bladder.
53440.........  Male sling procedure  ......  S             0385     79.2092    4,868.83  ..........      973.77
53442.........  Remove/revise male    ......  T             0168     29.0253    1,784.13      388.16      356.83
                 sling.
53444.........  Insert tandem cuff..  ......  S             0385     79.2092    4,868.83  ..........      973.77
53445.........  Insert uro/ves nck    ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 sphincter.
53446.........  Remove uro sphincter  ......  T             0168     29.0253    1,784.13      388.16      356.83
53447.........  Remove/replace ur     ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 sphincter.
53449.........  Repair uro sphincter  ......  T             0168     29.0253    1,784.13      388.16      356.83
53450.........  Revision of urethra.  ......  T             0168     29.0253    1,784.13      388.16      356.83
53460.........  Revision of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53500.........  Urethrlys, transvag   ......  T             0168     29.0253    1,784.13      388.16      356.83
                 w/ scope.
53502.........  Repair of urethra     ......  T             0166      18.396    1,130.77  ..........      226.15
                 injury.
53505.........  Repair of urethra     ......  T             0168     29.0253    1,784.13      388.16      356.83
                 injury.
53510.........  Repair of urethra     ......  T             0166      18.396    1,130.77  ..........      226.15
                 injury.
53515.........  Repair of urethra     ......  T             0168     29.0253    1,784.13      388.16      356.83
                 injury.
53520.........  Repair of urethra     ......  T             0168     29.0253    1,784.13      388.16      356.83
                 defect.
53600.........  Dilate urethra        ......  T             0156      3.4079      209.48  ..........       41.90
                 stricture.
53601.........  Dilate urethra         CH...  T             0126      1.0887       66.92       16.45       13.38
                 stricture.
53605.........  Dilate urethra        ......  T             0161     19.2251    1,181.73      249.36      236.35
                 stricture.
53620.........  Dilate urethra        ......  T             0165     18.1679    1,116.74  ..........      223.35
                 stricture.
53621.........  Dilate urethra        ......  T             0164      2.1393      131.50  ..........       26.30
                 stricture.
53660.........  Dilation of urethra.   CH...  T             0126      1.0887       66.92       16.45       13.38
53661.........  Dilation of urethra.   CH...  T             0126      1.0887       66.92       16.45       13.38
53665.........  Dilation of urethra.  ......  T             0166      18.396    1,130.77  ..........      226.15
53850.........  Prostatic microwave   ......  T             0675     41.1375    2,528.64  ..........      505.73
                 thermotx.
53852.........  Prostatic rf          ......  T             0675     41.1375    2,528.64  ..........      505.73
                 thermotx.
53853.........  Prostatic water       ......  T             0162       23.87    1,467.24  ..........      293.45
                 thermother.
53899.........  Urology surgery        CH...  T             0126      1.0887       66.92       16.45       13.38
                 procedure.
54000.........  Slitting of prepuce.  ......  T             0166      18.396    1,130.77  ..........      226.15
54001.........  Slitting of prepuce.  ......  T             0166      18.396    1,130.77  ..........      226.15
54015.........  Drain penis lesion..  ......  T             0008     17.5086    1,076.22  ..........      215.24
54050.........  Destruction, penis    ......  T             0013      1.0918       67.11  ..........       13.42
                 lesion(s).
54055.........  Destruction, penis    ......  T             0017     17.4423    1,072.14      227.84      214.43
                 lesion(s).
54056.........  Cryosurgery, penis    ......  T             0012      0.8432       51.83       11.18       10.37
                 lesion(s).
54057.........  Laser surg, penis     ......  T             0017     17.4423    1,072.14      227.84      214.43
                 lesion(s).
54060.........  Excision of penis     ......  T             0017     17.4423    1,072.14      227.84      214.43
                 lesion(s).
54065.........  Destruction, penis    ......  T             0695     20.4276    1,255.64      266.59      251.13
                 lesion(s).
54100.........  Biopsy of penis.....  ......  T             0021     15.1024      928.31      219.48      185.66
54105.........  Biopsy of penis.....  ......  T             0022     20.0656    1,233.39      354.45      246.68
54110.........  Treatment of penis    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 lesion.
54111.........  Treat penis lesion,   ......  T             0181     32.9873    2,027.66      621.82      405.53
                 graft.
54112.........  Treat penis lesion,   ......  T             0181     32.9873    2,027.66      621.82      405.53
                 graft.
54115.........  Treatment of penis    ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
54120.........  Partial removal of    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 penis.
54150.........  Circumcision w/       ......  T             0180     20.5513    1,263.25      304.87      252.65
                 regionl block.
54152.........  Circumcision........  ......  T             0180     20.5513    1,263.25      304.87      252.65
54160.........  Circumcision,         ......  T             0180     20.5513    1,263.25      304.87      252.65
                 neonate.
54161.........  Circum 28 days or     ......  T             0180     20.5513    1,263.25      304.87      252.65
                 older.
54162.........  Lysis penil circumic  ......  T             0180     20.5513    1,263.25      304.87      252.65
                 lesion.
54163.........  Repair of             ......  T             0180     20.5513    1,263.25      304.87      252.65
                 circumcision.
54164.........  Frenulotomy of penis  ......  T             0180     20.5513    1,263.25      304.87      252.65
54200.........  Treatment of penis     CH...  T             0164      2.1393      131.50  ..........       26.30
                 lesion.
54205.........  Treatment of penis    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 lesion.
54220.........  Treatment of penis     CH...  T             0164      2.1393      131.50  ..........       26.30
                 lesion.

[[Page 68329]]

 
54230.........  Prepare penis study.  ......  N       ..........  ..........  ..........  ..........  ..........
54231.........  Dynamic               ......  T             0165     18.1679    1,116.74  ..........      223.35
                 cavernosometry.
54235.........  Penile injection....  ......  T             0164      2.1393      131.50  ..........       26.30
54240.........  Penis study.........   CH...  T             0126      1.0887       66.92       16.45       13.38
54250.........  Penis study.........  ......  T             0164      2.1393      131.50  ..........       26.30
54300.........  Revision of penis...  ......  T             0181     32.9873    2,027.66      621.82      405.53
54304.........  Revision of penis...  ......  T             0181     32.9873    2,027.66      621.82      405.53
54308.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54312.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54316.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54318.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54322.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54324.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54326.........  Reconstruction of     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 urethra.
54328.........  Revise penis/urethra  ......  T             0181     32.9873    2,027.66      621.82      405.53
54340.........  Secondary urethral    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 surgery.
54344.........  Secondary urethral    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 surgery.
54348.........  Secondary urethral    ......  T             0181     32.9873    2,027.66      621.82      405.53
                 surgery.
54352.........  Reconstruct urethra/  ......  T             0181     32.9873    2,027.66      621.82      405.53
                 penis.
54360.........  Penis plastic         ......  T             0181     32.9873    2,027.66      621.82      405.53
                 surgery.
54380.........  Repair penis........  ......  T             0181     32.9873    2,027.66      621.82      405.53
54385.........  Repair penis........  ......  T             0181     32.9873    2,027.66      621.82      405.53
54400.........  Insert semi-rigid     ......  S             0385     79.2092    4,868.83  ..........      973.77
                 prosthesis.
54401.........  Insert self-contd     ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 prosthesis.
54405.........  Insert multi-comp     ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 penis pros.
54406.........  Remove muti-comp      ......  T             0181     32.9873    2,027.66      621.82      405.53
                 penis pros.
54408.........  Repair multi-comp     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 penis pros.
54410.........  Remove/replace penis  ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 prosth.
54415.........  Remove self-contd     ......  T             0181     32.9873    2,027.66      621.82      405.53
                 penis pros.
54416.........  Remv/repl penis       ......  S             0386    137.3897    8,445.07  ..........    1,689.01
                 contain pros.
54420.........  Revision of penis...  ......  T             0181     32.9873    2,027.66      621.82      405.53
54435.........  Revision of penis...  ......  T             0181     32.9873    2,027.66      621.82      405.53
54440.........  Repair of penis.....  ......  T             0181     32.9873    2,027.66      621.82      405.53
54450.........  Preputial stretching  ......  T             0156      3.4079      209.48  ..........       41.90
54500.........  Biopsy of testis....  ......  T             0037     10.2655      631.00      228.76      126.20
54505.........  Biopsy of testis....  ......  T             0183      23.531    1,446.40  ..........      289.28
54512.........  Excise lesion testis  ......  T             0183      23.531    1,446.40  ..........      289.28
54520.........  Removal of testis...  ......  T             0183      23.531    1,446.40  ..........      289.28
54522.........  Orchiectomy, partial  ......  T             0183      23.531    1,446.40  ..........      289.28
54530.........  Removal of testis...  ......  T             0154     29.2182    1,795.98      464.85      359.20
54550.........  Exploration for       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 testis.
54560.........  Exploration for       ......  T             0183      23.531    1,446.40  ..........      289.28
                 testis.
54600.........  Reduce testis         ......  T             0183      23.531    1,446.40  ..........      289.28
                 torsion.
54620.........  Suspension of testis  ......  T             0183      23.531    1,446.40  ..........      289.28
54640.........  Suspension of testis  ......  T             0154     29.2182    1,795.98      464.85      359.20
54660.........  Revision of testis..  ......  T             0183      23.531    1,446.40  ..........      289.28
54670.........  Repair testis injury  ......  T             0183      23.531    1,446.40  ..........      289.28
54680.........  Relocation of         ......  T             0183      23.531    1,446.40  ..........      289.28
                 testis(es).
54690.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 orchiectomy.
54692.........  Laparoscopy,          ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 orchiopexy.
54699.........  Laparoscope proc,     ......  T             0130     32.1241    1,974.60      659.53      394.92
                 testis.
54700.........  Drainage of scrotum.  ......  T             0183      23.531    1,446.40  ..........      289.28
54800.........  Biopsy of epididymis  ......  T             0004      2.0687      127.16  ..........       25.43
54820.........  Exploration of         CH...  D       ..........  ..........  ..........  ..........  ..........
                 epididymis.
54830.........  Remove epididymis     ......  T             0183      23.531    1,446.40  ..........      289.28
                 lesion.
54840.........  Remove epididymis     ......  T             0183      23.531    1,446.40  ..........      289.28
                 lesion.
54860.........  Removal of            ......  T             0183      23.531    1,446.40  ..........      289.28
                 epididymis.
54861.........  Removal of            ......  T             0183      23.531    1,446.40  ..........      289.28
                 epididymis.
54865.........  Explore epididymis..   NI...  T             0183      23.531    1,446.40  ..........      289.28
54900.........  Fusion of spermatic   ......  T             0183      23.531    1,446.40  ..........      289.28
                 ducts.
54901.........  Fusion of spermatic   ......  T             0183      23.531    1,446.40  ..........      289.28
                 ducts.
55000.........  Drainage of           ......  T             0004      2.0687      127.16  ..........       25.43
                 hydrocele.
55040.........  Removal of hydrocele  ......  T             0154     29.2182    1,795.98      464.85      359.20
55041.........  Removal of            ......  T             0154     29.2182    1,795.98      464.85      359.20
                 hydroceles.
55060.........  Repair of hydrocele.  ......  T             0183      23.531    1,446.40  ..........      289.28
55100.........  Drainage of scrotum    CH...  T             0007     11.1535      685.58  ..........      137.12
                 abscess.
55110.........  Explore scrotum.....  ......  T             0183      23.531    1,446.40  ..........      289.28
55120.........  Removal of scrotum    ......  T             0183      23.531    1,446.40  ..........      289.28
                 lesion.
55150.........  Removal of scrotum..  ......  T             0183      23.531    1,446.40  ..........      289.28
55175.........  Revision of scrotum.  ......  T             0183      23.531    1,446.40  ..........      289.28

[[Page 68330]]

 
55180.........  Revision of scrotum.  ......  T             0183      23.531    1,446.40  ..........      289.28
55200.........  Incision of sperm     ......  T             0183      23.531    1,446.40  ..........      289.28
                 duct.
55250.........  Removal of sperm      ......  T             0183      23.531    1,446.40  ..........      289.28
                 duct(s).
55300.........  Prepare, sperm duct   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-ray.
55400.........  Repair of sperm duct  ......  T             0183      23.531    1,446.40  ..........      289.28
55450.........  Ligation of sperm     ......  T             0183      23.531    1,446.40  ..........      289.28
                 duct.
55500.........  Removal of hydrocele  ......  T             0183      23.531    1,446.40  ..........      289.28
55520.........  Removal of sperm      ......  T             0183      23.531    1,446.40  ..........      289.28
                 cord lesion.
55530.........  Revise spermatic      ......  T             0183      23.531    1,446.40  ..........      289.28
                 cord veins.
55535.........  Revise spermatic      ......  T             0154     29.2182    1,795.98      464.85      359.20
                 cord veins.
55540.........  Revise hernia &       ......  T             0154     29.2182    1,795.98      464.85      359.20
                 sperm veins.
55550.........  Laparo ligate         ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 spermatic vein.
55559.........  Laparo proc,          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 spermatic cord.
55600.........  Incise sperm duct     ......  T             0183      23.531    1,446.40  ..........      289.28
                 pouch.
55680.........  Remove sperm pouch    ......  T             0183      23.531    1,446.40  ..........      289.28
                 lesion.
55700.........  Biopsy of prostate..  ......  T             0184      5.6262      345.83       96.27       69.17
55705.........  Biopsy of prostate..  ......  T             0184      5.6262      345.83       96.27       69.17
55720.........  Drainage of prostate  ......  T             0162       23.87    1,467.24  ..........      293.45
                 abscess.
55725.........  Drainage of prostate  ......  T             0162       23.87    1,467.24  ..........      293.45
                 abscess.
55859.........  Percut/needle          CH...  D       ..........  ..........  ..........  ..........  ..........
                 insert, pros.
55860.........  Surgical exposure,    ......  T             0165     18.1679    1,116.74  ..........      223.35
                 prostate.
55870.........  Electroejaculation..  ......  T             0197      4.0007      245.92  ..........       49.18
55873.........  Cryoablate prostate.  ......  T             0674    108.7566    6,685.05  ..........    1,337.01
55875.........  Transperi needle       NI...  T             0163     34.9261    2,146.84  ..........      429.37
                 place, pros.
55876.........  Place rt device/       NI...  T             0156      3.4079      209.48  ..........       41.90
                 marker, pros.
55899.........  Genital surgery        CH...  T             0126      1.0887       66.92       16.45       13.38
                 procedure.
56405.........  I & D of vulva/       ......  T             0189      2.8966      178.05  ..........       35.61
                 perineum.
56420.........  Drainage of gland      CH...  T             0188        1.29       79.29  ..........       15.86
                 abscess.
56440.........  Surgery for vulva     ......  T             0194     20.5081    1,260.59      397.84      252.12
                 lesion.
56441.........  Lysis of labial       ......  T             0193     14.8489      912.73  ..........      182.55
                 lesion(s).
56442.........  Hymenotomy..........   NI...  T             0193     14.8489      912.73  ..........      182.55
56501.........  Destroy, vulva        ......  T             0017     17.4423    1,072.14      227.84      214.43
                 lesions, sim.
56515.........  Destroy vulva lesion/ ......  T             0695     20.4276    1,255.64      266.59      251.13
                 s compl.
56605.........  Biopsy of vulva/      ......  T             0019      4.0919      251.52       71.87       50.30
                 perineum.
56606.........  Biopsy of vulva/      ......  T             0019      4.0919      251.52       71.87       50.30
                 perineum.
56620.........  Partial removal of    ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vulva.
56625.........  Complete removal of   ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vulva.
56700.........  Partial removal of    ......  T             0194     20.5081    1,260.59      397.84      252.12
                 hymen.
56720.........  Incision of hymen...   CH...  D       ..........  ..........  ..........  ..........  ..........
56740.........  Remove vagina gland   ......  T             0194     20.5081    1,260.59      397.84      252.12
                 lesion.
56800.........  Repair of vagina....  ......  T             0194     20.5081    1,260.59      397.84      252.12
56805.........  Repair clitoris.....  ......  T             0193     14.8489      912.73  ..........      182.55
56810.........  Repair of perineum..  ......  T             0194     20.5081    1,260.59      397.84      252.12
56820.........  Exam of vulva w/      ......  T             0188        1.29       79.29  ..........       15.86
                 scope.
56821.........  Exam/biopsy of vulva  ......  T             0189      2.8966      178.05  ..........       35.61
                 w/scope.
57000.........  Exploration of        ......  T             0193     14.8489      912.73  ..........      182.55
                 vagina.
57010.........  Drainage of pelvic    ......  T             0193     14.8489      912.73  ..........      182.55
                 abscess.
57020.........  Drainage of pelvic    ......  T             0192      6.6592      409.33  ..........       81.87
                 fluid.
57022.........  I & d vaginal         ......  T             0007     11.1535      685.58  ..........      137.12
                 hematoma, pp.
57023.........  I & d vag hematoma,   ......  T             0008     17.5086    1,076.22  ..........      215.24
                 non-ob.
57061.........  Destroy vag lesions,  ......  T             0194     20.5081    1,260.59      397.84      252.12
                 simple.
57065.........  Destroy vag lesions,  ......  T             0194     20.5081    1,260.59      397.84      252.12
                 complex.
57100.........  Biopsy of vagina....  ......  T             0192      6.6592      409.33  ..........       81.87
57105.........  Biopsy of vagina....  ......  T             0194     20.5081    1,260.59      397.84      252.12
57106.........  Remove vagina wall,   ......  T             0194     20.5081    1,260.59      397.84      252.12
                 partial.
57107.........  Remove vagina         ......  T             0195     28.5095    1,752.42      483.80      350.48
                 tissue, part.
57109.........  Vaginectomy partial   ......  T             0195     28.5095    1,752.42      483.80      350.48
                 w/nodes.
57120.........  Closure of vagina...  ......  T             0195     28.5095    1,752.42      483.80      350.48
57130.........  Remove vagina lesion  ......  T             0194     20.5081    1,260.59      397.84      252.12
57135.........  Remove vagina lesion  ......  T             0194     20.5081    1,260.59      397.84      252.12
57150.........  Treat vagina          ......  T             0191      0.1468        9.02        2.55        1.80
                 infection.
57155.........  Insert uteri tandems/ ......  T             0192      6.6592      409.33  ..........       81.87
                 ovoids.
57160.........  Insert pessary/other  ......  T             0188        1.29       79.29  ..........       15.86
                 device.
57170.........  Fitting of diaphragm/ ......  T             0191      0.1468        9.02        2.55        1.80
                 cap.
57180.........  Treat vaginal         ......  T             0189      2.8966      178.05  ..........       35.61
                 bleeding.
57200.........  Repair of vagina....  ......  T             0194     20.5081    1,260.59      397.84      252.12
57210.........  Repair vagina/        ......  T             0194     20.5081    1,260.59      397.84      252.12
                 perineum.
57220.........  Revision of urethra.  ......  T             0202     42.9896    2,642.48      981.50      528.50
57230.........  Repair of urethral    ......  T             0195     28.5095    1,752.42      483.80      350.48
                 lesion.
57240.........  Repair bladder &      ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina.

[[Page 68331]]

 
57250.........  Repair rectum &       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina.
57260.........  Repair of vagina....  ......  T             0195     28.5095    1,752.42      483.80      350.48
57265.........  Extensive repair of   ......  T             0202     42.9896    2,642.48      981.50      528.50
                 vagina.
57267.........  Insert mesh/pelvic     CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 flr addon.
57268.........  Repair of bowel       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 bulge.
57282.........  Colpopexy,             CH...  T             0202     42.9896    2,642.48      981.50      528.50
                 extraperitoneal.
57283.........  Colpopexy,             CH...  T             0202     42.9896    2,642.48      981.50      528.50
                 intraperitoneal.
57284.........  Repair paravaginal    ......  T             0202     42.9896    2,642.48      981.50      528.50
                 defect.
57287.........  Revise/remove sling    CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 repair.
57288.........  Repair bladder        ......  T             0202     42.9896    2,642.48      981.50      528.50
                 defect.
57289.........  Repair bladder &      ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina.
57291.........  Construction of       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina.
57292.........  Construct vagina       CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 with graft.
57295.........  Change vaginal graft  ......  T             0194     20.5081    1,260.59      397.84      252.12
57296.........  Revise vag graft,      NI...  C       ..........  ..........  ..........  ..........  ..........
                 open abd.
57300.........  Repair rectum-vagina  ......  T             0195     28.5095    1,752.42      483.80      350.48
                 fistula.
57310.........  Repair                ......  T             0202     42.9896    2,642.48      981.50      528.50
                 urethrovaginal
                 lesion.
57320.........  Repair bladder-       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina lesion.
57330.........  Repair bladder-       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina lesion.
57335.........  Repair vagina.......   CH...  T             0195     28.5095    1,752.42      483.80      350.48
57400.........  Dilation of vagina..  ......  T             0194     20.5081    1,260.59      397.84      252.12
57410.........  Pelvic examination..  ......  T             0193     14.8489      912.73  ..........      182.55
57415.........  Remove vaginal        ......  T             0194     20.5081    1,260.59      397.84      252.12
                 foreign body.
57420.........  Exam of vagina w/     ......  T             0189      2.8966      178.05  ..........       35.61
                 scope.
57421.........  Exam/biopsy of vag w/ ......  T             0189      2.8966      178.05  ..........       35.61
                 scope.
57425.........  Laparoscopy, surg,    ......  T             0130     32.1241    1,974.60      659.53      394.92
                 colpopexy.
57452.........  Exam of cervix w/      CH...  T             0188        1.29       79.29  ..........       15.86
                 scope.
57454.........  Bx/curett of cervix   ......  T             0189      2.8966      178.05  ..........       35.61
                 w/scope.
57455.........  Biopsy of cervix w/   ......  T             0189      2.8966      178.05  ..........       35.61
                 scope.
57456.........  Endocerv curettage w/ ......  T             0189      2.8966      178.05  ..........       35.61
                 scope.
57460.........  Bx of cervix w/       ......  T             0193     14.8489      912.73  ..........      182.55
                 scope, leep.
57461.........  Conz of cervix w/     ......  T             0194     20.5081    1,260.59      397.84      252.12
                 scope, leep.
57500.........  Biopsy of cervix....   CH...  T             0189      2.8966      178.05  ..........       35.61
57505.........  Endocervical          ......  T             0189      2.8966      178.05  ..........       35.61
                 curettage.
57510.........  Cauterization of      ......  T             0193     14.8489      912.73  ..........      182.55
                 cervix.
57511.........  Cryocautery of         CH...  T             0188        1.29       79.29  ..........       15.86
                 cervix.
57513.........  Laser surgery of      ......  T             0193     14.8489      912.73  ..........      182.55
                 cervix.
57520.........  Conization of cervix  ......  T             0194     20.5081    1,260.59      397.84      252.12
57522.........  Conization of cervix  ......  T             0195     28.5095    1,752.42      483.80      350.48
57530.........  Removal of cervix...  ......  T             0195     28.5095    1,752.42      483.80      350.48
57550.........  Removal of residual   ......  T             0195     28.5095    1,752.42      483.80      350.48
                 cervix.
57555.........  Remove cervix/repair  ......  T             0195     28.5095    1,752.42      483.80      350.48
                 vagina.
57556.........  Remove cervix,        ......  T             0202     42.9896    2,642.48      981.50      528.50
                 repair bowel.
57558.........  D&c of cervical        NI...  T             0196     17.7499    1,091.05      338.23      218.21
                 stump.
57700.........  Revision of cervix..  ......  T             0194     20.5081    1,260.59      397.84      252.12
57720.........  Revision of cervix..  ......  T             0194     20.5081    1,260.59      397.84      252.12
57800.........  Dilation of cervical  ......  T             0193     14.8489      912.73  ..........      182.55
                 canal.
57820.........  D & c of residual      CH...  D       ..........  ..........  ..........  ..........  ..........
                 cervix.
58100.........  Biopsy of uterus      ......  T             0188        1.29       79.29  ..........       15.86
                 lining.
58110.........  Bx done w/colposcopy  ......  T             0188        1.29       79.29  ..........       15.86
                 add-on.
58120.........  Dilation and          ......  T             0196     17.7499    1,091.05      338.23      218.21
                 curettage.
58145.........  Myomectomy vag        ......  T             0195     28.5095    1,752.42      483.80      350.48
                 method.
58260.........  Vaginal hysterectomy   CH...  T             0195     28.5095    1,752.42      483.80      350.48
58262.........  Vag hyst including t/  CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 o.
58263.........  Vag hyst w/t/o & vag   CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 repair.
58270.........  Vag hyst w/            CH...  T             0195     28.5095    1,752.42      483.80      350.48
                 enterocele repair.
58290.........  Vag hyst complex....   CH...  T             0202     42.9896    2,642.48      981.50      528.50
58291.........  Vag hyst incl t/o,     CH...  T             0202     42.9896    2,642.48      981.50      528.50
                 complex.
58292.........  Vag hyst t/o &         CH...  T             0202     42.9896    2,642.48      981.50      528.50
                 repair, compl.
58294.........  Vag hyst w/            CH...  T             0202     42.9896    2,642.48      981.50      528.50
                 enterocele, compl.
58301.........  Remove intrauterine    CH...  T             0188        1.29       79.29  ..........       15.86
                 device.
58321.........  Artificial            ......  T             0197      4.0007      245.92  ..........       49.18
                 insemination.
58322.........  Artificial            ......  T             0197      4.0007      245.92  ..........       49.18
                 insemination.
58323.........  Sperm washing.......  ......  T             0197      4.0007      245.92  ..........       49.18
58340.........  Catheter for          ......  N       ..........  ..........  ..........  ..........  ..........
                 hysterography.
58345.........  Reopen fallopian      ......  T             0193     14.8489      912.73  ..........      182.55
                 tube.
58346.........  Insert heyman uteri   ......  T             0193     14.8489      912.73  ..........      182.55
                 capsule.
58350.........  Reopen fallopian      ......  T             0195     28.5095    1,752.42      483.80      350.48
                 tube.
58353.........  Endometr ablate,      ......  T             0195     28.5095    1,752.42      483.80      350.48
                 thermal.
58356.........  Endometrial           ......  T             0202     42.9896    2,642.48      981.50      528.50
                 cryoablation.

[[Page 68332]]

 
58541.........  Lsh, uterus 250 g or   NI...  T             0131     43.5488    2,676.86    1,001.89      535.37
                 less.
58542.........  Lsh w/t/o ut 250 g     NI...  T             0131     43.5488    2,676.86    1,001.89      535.37
                 or less.
58543.........  Lsh uterus above 250   NI...  T             0131     43.5488    2,676.86    1,001.89      535.37
                 g.
58544.........  Lsh w/t/o uterus       NI...  T             0131     43.5488    2,676.86    1,001.89      535.37
                 above 250 g.
58545.........  Laparoscopic          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 myomectomy.
58546.........  Laparo-myomectomy,    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 complex.
58548.........  Lap radical hyst....   NI...  C       ..........  ..........  ..........  ..........  ..........
58550.........  Laparo-asst vag       ......  T             0132     70.5066    4,333.90    1,239.22      866.78
                 hysterectomy.
58552.........  Laparo-vag hyst incl  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 t/o.
58553.........  Laparo-vag hyst,      ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 complex.
58554.........  Laparo-vag hyst w/t/  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 o, compl.
58555.........  Hysteroscopy, dx,     ......  T             0190     21.3586    1,312.87      424.28      262.57
                 sep proc.
58558.........  Hysteroscopy, biopsy  ......  T             0190     21.3586    1,312.87      424.28      262.57
58559.........  Hysteroscopy, lysis.  ......  T             0190     21.3586    1,312.87      424.28      262.57
58560.........  Hysteroscopy, resect  ......  T             0387     34.0155    2,090.86      655.55      418.17
                 septum.
58561.........  Hysteroscopy, remove  ......  T             0387     34.0155    2,090.86      655.55      418.17
                 myoma.
58562.........  Hysteroscopy, remove  ......  T             0190     21.3586    1,312.87      424.28      262.57
                 fb.
58563.........  Hysteroscopy,         ......  T             0387     34.0155    2,090.86      655.55      418.17
                 ablation.
58565.........  Hysteroscopy,         ......  T             0202     42.9896    2,642.48      981.50      528.50
                 sterilization.
58578.........  Laparo proc, uterus.  ......  T             0130     32.1241    1,974.60      659.53      394.92
58579.........  Hysteroscope          ......  T             0190     21.3586    1,312.87      424.28      262.57
                 procedure.
58600.........  Division of           ......  T             0195     28.5095    1,752.42      483.80      350.48
                 fallopian tube.
58615.........  Occlude fallopian     ......  T             0194     20.5081    1,260.59      397.84      252.12
                 tube(s).
58660.........  Laparoscopy, lysis..  ......  T             0131     43.5488    2,676.86    1,001.89      535.37
58661.........  Laparoscopy, remove   ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 adnexa.
58662.........  Laparoscopy, excise   ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 lesions.
58670.........  Laparoscopy, tubal    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 cautery.
58671.........  Laparoscopy, tubal    ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 block.
58672.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 fimbrioplasty.
58673.........  Laparoscopy,          ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 salpingostomy.
58679.........  Laparo proc, oviduct- ......  T             0130     32.1241    1,974.60      659.53      394.92
                 ovary.
58770.........  Create new tubal      ......  T             0195     28.5095    1,752.42      483.80      350.48
                 opening.
58800.........  Drainage of ovarian   ......  T             0193     14.8489      912.73  ..........      182.55
                 cyst(s).
58820.........  Drain ovary abscess,  ......  T             0195     28.5095    1,752.42      483.80      350.48
                 open.
58823.........  Drain pelvic          ......  T             0193     14.8489      912.73  ..........      182.55
                 abscess, percut.
58900.........  Biopsy of ovary(s)..  ......  T             0193     14.8489      912.73  ..........      182.55
58920.........  Partial removal of    ......  T             0195     28.5095    1,752.42      483.80      350.48
                 ovary(s).
58925.........  Removal of ovarian    ......  T             0195     28.5095    1,752.42      483.80      350.48
                 cyst(s).
58957.........  Resect recurrent gyn   NI...  C       ..........  ..........  ..........  ..........  ..........
                 mal.
58958.........  Resect recur gyn mal   NI...  C       ..........  ..........  ..........  ..........  ..........
                 w/lym.
58970.........  Retrieval of oocyte.  ......  T             0197      4.0007      245.92  ..........       49.18
58974.........  Transfer of embryo..  ......  T             0197      4.0007      245.92  ..........       49.18
58976.........  Transfer of embryo..  ......  T             0197      4.0007      245.92  ..........       49.18
58999.........  Genital surgery       ......  T             0191      0.1468        9.02        2.55        1.80
                 procedure.
59000.........  Amniocentesis,        ......  T             0198      1.4222       87.42       32.19       17.48
                 diagnostic.
59001.........  Amniocentesis,        ......  T             0192      6.6592      409.33  ..........       81.87
                 therapeutic.
59012.........  Fetal cord            ......  T             0198      1.4222       87.42       32.19       17.48
                 puncture,prenatal.
59015.........  Chorion biopsy......  ......  T             0198      1.4222       87.42       32.19       17.48
59020.........  Fetal contract         CH...  T             0189      2.8966      178.05  ..........       35.61
                 stress test.
59025.........  Fetal non-stress      ......  T             0198      1.4222       87.42       32.19       17.48
                 test.
59030.........  Fetal scalp blood     ......  T             0198      1.4222       87.42       32.19       17.48
                 sample.
59070.........  Transabdom            ......  T             0198      1.4222       87.42       32.19       17.48
                 amnioinfus w/us.
59072.........  Umbilical cord        ......  T             0198      1.4222       87.42       32.19       17.48
                 occlud w/us.
59074.........  Fetal fluid drainage  ......  T             0198      1.4222       87.42       32.19       17.48
                 w/us.
59076.........  Fetal shunt           ......  T             0198      1.4222       87.42       32.19       17.48
                 placement, w/us.
59100.........  Remove uterus lesion  ......  T             0195     28.5095    1,752.42      483.80      350.48
59150.........  Treat ectopic         ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 pregnancy.
59151.........  Treat ectopic         ......  T             0131     43.5488    2,676.86    1,001.89      535.37
                 pregnancy.
59160.........  D& c after delivery.  ......  T             0196     17.7499    1,091.05      338.23      218.21
59200.........  Insert cervical       ......  T             0189      2.8966      178.05  ..........       35.61
                 dilator.
59300.........  Episiotomy or         ......  T             0193     14.8489      912.73  ..........      182.55
                 vaginal repair.
59320.........  Revision of cervix..  ......  T             0194     20.5081    1,260.59      397.84      252.12
59409.........  Obstetrical care....  ......  T             0194     20.5081    1,260.59      397.84      252.12
59412.........  Antepartum            ......  T             0700      2.3864      146.69  ..........       29.34
                 manipulation.
59414.........  Deliver placenta....  ......  T             0193     14.8489      912.73  ..........      182.55
59612.........  Vbac delivery only..  ......  T             0194     20.5081    1,260.59      397.84      252.12
59812.........  Treatment of          ......  T             0201     18.5201    1,138.39      329.65      227.68
                 miscarriage.
59820.........  Care of miscarriage.  ......  T             0201     18.5201    1,138.39      329.65      227.68
59821.........  Treatment of          ......  T             0201     18.5201    1,138.39      329.65      227.68
                 miscarriage.
59840.........  Abortion............  ......  T             0200     16.9328    1,040.83      243.36      208.17

[[Page 68333]]

 
59841.........  Abortion............  ......  T             0200     16.9328    1,040.83      243.36      208.17
59866.........  Abortion (mpr)......  ......  T             0198      1.4222       87.42       32.19       17.48
59870.........  Evacuate mole of      ......  T             0201     18.5201    1,138.39      329.65      227.68
                 uterus.
59871.........  Remove cerclage       ......  T             0194     20.5081    1,260.59      397.84      252.12
                 suture.
59897.........  Fetal invas px w/us.  ......  T             0198      1.4222       87.42       32.19       17.48
59898.........  Laparo proc, ob care/ ......  T             0130     32.1241    1,974.60      659.53      394.92
                 deliver.
59899.........  Maternity care        ......  T             0198      1.4222       87.42       32.19       17.48
                 procedure.
60000.........  Drain thyroid/tongue  ......  T             0252      7.5511      464.15      109.16       92.83
                 cyst.
60001.........  Aspirate/inject       ......  T             0004      2.0687      127.16  ..........       25.43
                 thyriod cyst.
60100.........  Biopsy of thyroid...  ......  T             0004      2.0687      127.16  ..........       25.43
60200.........  Remove thyroid        ......  T             0114     37.7224    2,318.72      467.95      463.74
                 lesion.
60210.........  Partial thyroid       ......  T             0114     37.7224    2,318.72      467.95      463.74
                 excision.
60212.........  Partial thyroid       ......  T             0114     37.7224    2,318.72      467.95      463.74
                 excision.
60220.........  Partial removal of    ......  T             0114     37.7224    2,318.72      467.95      463.74
                 thyroid.
60225.........  Partial removal of    ......  T             0114     37.7224    2,318.72      467.95      463.74
                 thyroid.
60240.........  Removal of thyroid..  ......  T             0114     37.7224    2,318.72      467.95      463.74
60252.........  Removal of thyroid..  ......  T             0256     38.1991    2,348.02  ..........      469.60
60260.........  Repeat thyroid        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 surgery.
60280.........  Remove thyroid duct   ......  T             0114     37.7224    2,318.72      467.95      463.74
                 lesion.
60281.........  Remove thyroid duct   ......  T             0114     37.7224    2,318.72      467.95      463.74
                 lesion.
60500.........  Explore parathyroid   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 glands.
60502.........  Re-explore             CH...  T             0256     38.1991    2,348.02  ..........      469.60
                 parathyroids.
60512.........  Autotransplant        ......  T             0022     20.0656    1,233.39      354.45      246.68
                 parathyroid.
60520.........  Removal of thymus      CH...  T             0256     38.1991    2,348.02  ..........      469.60
                 gland.
60659.........  Laparo proc,          ......  T             0130     32.1241    1,974.60      659.53      394.92
                 endocrine.
60699.........  Endocrine surgery     ......  T             0114     37.7224    2,318.72      467.95      463.74
                 procedure.
61000.........  Remove cranial        ......  T             0212      2.9907      183.83       65.96       36.77
                 cavity fluid.
61001.........  Remove cranial        ......  T             0212      2.9907      183.83       65.96       36.77
                 cavity fluid.
61020.........  Remove brain cavity   ......  T             0212      2.9907      183.83       65.96       36.77
                 fluid.
61026.........  Injection into brain  ......  T             0212      2.9907      183.83       65.96       36.77
                 canal.
61050.........  Remove brain canal    ......  T             0212      2.9907      183.83       65.96       36.77
                 fluid.
61055.........  Injection into brain  ......  T             0212      2.9907      183.83       65.96       36.77
                 canal.
61070.........  Brain canal shunt     ......  T             0212      2.9907      183.83       65.96       36.77
                 procedure.
61215.........  Insert brain-fluid    ......  T             0224     47.0342    2,891.10  ..........      578.22
                 device.
61330.........  Decompress eye        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 socket.
61334.........  Explore orbit/remove  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 object.
61623.........  Endovasc tempory      ......  T             0081      42.936    2,639.19  ..........      527.84
                 vessel occl.
61626.........  Transcath occlusion,  ......  T             0081      42.936    2,639.19  ..........      527.84
                 non-cns.
61720.........  Incise skull/brain     CH...  T             0221      33.152    2,037.79      463.62      407.56
                 surgery.
61790.........  Treat trigeminal      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
61791.........  Treat trigeminal      ......  T             0206      5.7253      351.92       75.55       70.38
                 tract.
61795.........  Brain surgery using   ......  S             0302      4.9138      302.04      105.94       60.41
                 computer.
61880.........  Revise/remove         ......  T             0687     17.8334    1,096.18      438.47      219.24
                 neuroelectrode.
61885.........  Insrt/redo neurostim  ......  S             0039    187.3821   11,518.00  ..........    2,303.60
                 1 array.
61886.........  Implant neurostim     ......  T             0315    242.9363   14,932.81  ..........    2,986.56
                 arrays.
61888.........  Revise/remove         ......  T             0688     35.5702    2,186.43      874.57      437.29
                 neuroreceiver.
62000.........  Treat skull fracture   CH...  T             0254     23.3299    1,434.04      321.35      286.81
62160.........  Neuroendoscopy add-   ......  T             0122        7.48      459.78  ..........       91.96
                 on.
62194.........  Replace/irrigate      ......  T             0427     11.6575      716.56  ..........      143.31
                 catheter.
62225.........  Replace/irrigate      ......  T             0427     11.6575      716.56  ..........      143.31
                 catheter.
62230.........  Replace/revise brain  ......  T             0224     47.0342    2,891.10  ..........      578.22
                 shunt.
62252.........  Csf shunt reprogram.  ......  S             0691      2.8942      177.90       60.61       35.58
62263.........  Epidural lysis mult   ......  T             0203     12.1702      748.08      240.33      149.62
                 sessions.
62264.........  Epidural lysis on     ......  T             0203     12.1702      748.08      240.33      149.62
                 single day.
62268.........  Drain spinal cord     ......  T             0212      2.9907      183.83       65.96       36.77
                 cyst.
62269.........  Needle biopsy,        ......  T             0685      6.1384      377.32      115.47       75.46
                 spinal cord.
62270.........  Spinal fluid tap,     ......  T             0204      2.2614      139.00       40.13       27.80
                 diagnostic.
62272.........  Drain cerebro spinal  ......  T             0204      2.2614      139.00       40.13       27.80
                 fluid.
62273.........  Inject epidural       ......  T             0206      5.7253      351.92       75.55       70.38
                 patch.
62280.........  Treat spinal cord     ......  T             0207      6.3603      390.95       86.92       78.19
                 lesion.
62281.........  Treat spinal cord     ......  T             0207      6.3603      390.95       86.92       78.19
                 lesion.
62282.........  Treat spinal canal    ......  T             0207      6.3603      390.95       86.92       78.19
                 lesion.
62284.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 myelogram.
62287.........  Percutaneous          ......  T             0221      33.152    2,037.79      463.62      407.56
                 diskectomy.
62290.........  Inject for spine      ......  N       ..........  ..........  ..........  ..........  ..........
                 disk x-ray.
62291.........  Inject for spine      ......  N       ..........  ..........  ..........  ..........  ..........
                 disk x-ray.
62292.........  Injection into disk   ......  T             0212      2.9907      183.83       65.96       36.77
                 lesion.
62294.........  Injection into        ......  T             0212      2.9907      183.83       65.96       36.77
                 spinal artery.
62310.........  Inject spine c/t....  ......  T             0207      6.3603      390.95       86.92       78.19
62311.........  Inject spine l/s      ......  T             0207      6.3603      390.95       86.92       78.19
                 (cd).

[[Page 68334]]

 
62318.........  Inject spine w/cath,  ......  T             0207      6.3603      390.95       86.92       78.19
                 c/t.
62319.........  Inject spine w/cath   ......  T             0207      6.3603      390.95       86.92       78.19
                 l/s (cd).
62350.........  Implant spinal canal  ......  T             0223     30.8394    1,895.64  ..........      379.13
                 cath.
62351.........  Implant spinal canal  ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cath.
62355.........  Remove spinal canal   ......  T             0203     12.1702      748.08      240.33      149.62
                 catheter.
62360.........  Insert spine          ......  T             0226    112.6322    6,923.28  ..........    1,384.66
                 infusion device.
62361.........  Implant spine         ......  T             0227    174.4056   10,720.36  ..........    2,144.07
                 infusion pump.
62362.........  Implant spine         ......  T             0227    174.4056   10,720.36  ..........    2,144.07
                 infusion pump.
62365.........  Remove spine          ......  T             0221      33.152    2,037.79      463.62      407.56
                 infusion device.
62367.........  Analyze spine         ......  S             0691      2.8942      177.90       60.61       35.58
                 infusion pump.
62368.........  Analyze spine         ......  S             0691      2.8942      177.90       60.61       35.58
                 infusion pump.
63001.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63003.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63005.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63011.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63012.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63015.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63016.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63017.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63020.........  Neck spine disk       ......  T             0208     44.1489    2,713.74  ..........      542.75
                 surgery.
63030.........  Low back disk         ......  T             0208     44.1489    2,713.74  ..........      542.75
                 surgery.
63035.........  Spinal disk surgery   ......  T             0208     44.1489    2,713.74  ..........      542.75
                 add-on.
63040.........  Laminotomy, single    ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cervical.
63042.........  Laminotomy, single    ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lumbar.
63045.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63046.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63047.........  Removal of spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 lamina.
63048.........  Remove spinal lamina  ......  T             0208     44.1489    2,713.74  ..........      542.75
                 add-on.
63055.........  Decompress spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cord.
63056.........  Decompress spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cord.
63057.........  Decompress spine      ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cord add-on.
63064.........  Decompress spinal     ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cord.
63066.........  Decompress spine      ......  T             0208     44.1489    2,713.74  ..........      542.75
                 cord add-on.
63075.........  Neck spine disk       ......  T             0208     44.1489    2,713.74  ..........      542.75
                 surgery.
63600.........  Remove spinal cord    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
63610.........  Stimulation of        ......  T             0220     17.8499    1,097.20  ..........      219.44
                 spinal cord.
63615.........  Remove lesion of      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 spinal cord.
63650.........  Implant               ......  S             0040     56.5705    3,477.28  ..........      695.46
                 neuroelectrodes.
63655.........  Implant               ......  S             0061     84.1967    5,175.40  ..........    1,035.08
                 neuroelectrodes.
63660.........  Revise/remove         ......  T             0687     17.8334    1,096.18      438.47      219.24
                 neuroelectrode.
63685.........  Insrt/redo spine n    ......  T             0222    181.6249   11,164.12  ..........    2,232.82
                 generator.
63688.........  Revise/remove         ......  T             0688     35.5702    2,186.43      874.57      437.29
                 neuroreceiver.
63741.........  Install spinal shunt  ......  T             0228     39.2633    2,413.44  ..........      482.69
63744.........  Revision of spinal    ......  T             0228     39.2633    2,413.44  ..........      482.69
                 shunt.
63746.........  Removal of spinal     ......  T             0109     10.9918      675.64  ..........      135.13
                 shunt.
64400.........  Nblock inj,           ......  T             0204      2.2614      139.00       40.13       27.80
                 trigeminal.
64402.........  Nblock inj, facial..  ......  T             0204      2.2614      139.00       40.13       27.80
64405.........  Nblock inj,           ......  T             0204      2.2614      139.00       40.13       27.80
                 occipital.
64408.........  Nblock inj, vagus...  ......  T             0204      2.2614      139.00       40.13       27.80
64410.........  Nblock inj, phrenic.  ......  T             0206      5.7253      351.92       75.55       70.38
64412.........  Nblock inj, spinal    ......  T             0206      5.7253      351.92       75.55       70.38
                 accessor.
64413.........  Nblock inj, cervical  ......  T             0204      2.2614      139.00       40.13       27.80
                 plexus.
64415.........  Nblock inj, brachial  ......  T             0204      2.2614      139.00       40.13       27.80
                 plexus.
64416.........  Nblock cont infuse,   ......  T             0204      2.2614      139.00       40.13       27.80
                 b plex.
64417.........  Nblock inj, axillary  ......  T             0204      2.2614      139.00       40.13       27.80
64418.........  Nblock inj,           ......  T             0204      2.2614      139.00       40.13       27.80
                 suprascapular.
64420.........  Nblock inj,           ......  T             0204      2.2614      139.00       40.13       27.80
                 intercost, sng.
64421.........  Nblock inj,           ......  T             0206      5.7253      351.92       75.55       70.38
                 intercost, mlt.
64425.........  Nblock inj, ilio-ing/ ......  T             0204      2.2614      139.00       40.13       27.80
                 hypogi.
64430.........  Nblock inj, pudendal  ......  T             0204      2.2614      139.00       40.13       27.80
64435.........  Nblock inj,           ......  T             0204      2.2614      139.00       40.13       27.80
                 paracervical.
64445.........  Nblock inj, sciatic,  ......  T             0204      2.2614      139.00       40.13       27.80
                 sng.
64446.........  Nblk inj, sciatic,    ......  T             0206      5.7253      351.92       75.55       70.38
                 cont inf.
64447.........  Nblock inj fem,       ......  T             0204      2.2614      139.00       40.13       27.80
                 single.
64448.........  Nblock inj fem, cont  ......  T             0204      2.2614      139.00       40.13       27.80
                 inf.
64449.........  Nblock inj, lumbar    ......  T             0204      2.2614      139.00       40.13       27.80
                 plexus.
64450.........  Nblock, other         ......  T             0204      2.2614      139.00       40.13       27.80
                 peripheral.
64470.........  Inj paravertebral c/  ......  T             0207      6.3603      390.95       86.92       78.19
                 t.
64472.........  Inj paravertebral c/  ......  T             0206      5.7253      351.92       75.55       70.38
                 t add-on.
64475.........  Inj paravertebral l/  ......  T             0207      6.3603      390.95       86.92       78.19
                 s.

[[Page 68335]]

 
64476.........  Inj paravertebral l/  ......  T             0206      5.7253      351.92       75.55       70.38
                 s add-on.
64479.........  Inj foramen epidural  ......  T             0207      6.3603      390.95       86.92       78.19
                 c/t.
64480.........  Inj foramen epidural  ......  T             0207      6.3603      390.95       86.92       78.19
                 add-on.
64483.........  Inj foramen epidural  ......  T             0207      6.3603      390.95       86.92       78.19
                 l/s.
64484.........  Inj foramen epidural  ......  T             0207      6.3603      390.95       86.92       78.19
                 add-on.
64505.........  Nblock,               ......  T             0204      2.2614      139.00       40.13       27.80
                 spenopalatine gangl.
64508.........  Nblock, carotid       ......  T             0204      2.2614      139.00       40.13       27.80
                 sinus s/p.
64510.........  Nblock, stellate      ......  T             0207      6.3603      390.95       86.92       78.19
                 ganglion.
64517.........  Nblock inj, hypogas   ......  T             0204      2.2614      139.00       40.13       27.80
                 plxs.
64520.........  Nblock, lumbar/       ......  T             0207      6.3603      390.95       86.92       78.19
                 thoracic.
64530.........  Nblock inj, celiac    ......  T             0207      6.3603      390.95       86.92       78.19
                 pelus.
64553.........  Implant               ......  S             0225    221.1512   13,593.72  ..........    2,718.74
                 neuroelectrodes.
64555.........  Implant               ......  S             0040     56.5705    3,477.28  ..........      695.46
                 neuroelectrodes.
64560.........  Implant               ......  S             0040     56.5705    3,477.28  ..........      695.46
                 neuroelectrodes.
64561.........  Implant               ......  S             0040     56.5705    3,477.28  ..........      695.46
                 neuroelectrodes.
64565.........  Implant               ......  S             0040     56.5705    3,477.28  ..........      695.46
                 neuroelectrodes.
64573.........  Implant               ......  S             0225    221.1512   13,593.72  ..........    2,718.74
                 neuroelectrodes.
64575.........  Implant               ......  S             0061     84.1967    5,175.40  ..........    1,035.08
                 neuroelectrodes.
64577.........  Implant               ......  S             0061     84.1967    5,175.40  ..........    1,035.08
                 neuroelectrodes.
64580.........  Implant               ......  S             0061     84.1967    5,175.40  ..........    1,035.08
                 neuroelectrodes.
64581.........  Implant               ......  S             0061     84.1967    5,175.40  ..........    1,035.08
                 neuroelectrodes.
64585.........  Revise/remove         ......  T             0687     17.8334    1,096.18      438.47      219.24
                 neuroelectrode.
64590.........  Insrt/redo pn/gastr   ......  T             0222    181.6249   11,164.12  ..........    2,232.82
                 stimul.
64595.........  Revise/rmv pn/gastr   ......  T             0688     35.5702    2,186.43      874.57      437.29
                 stimul.
64600.........  Injection treatment   ......  T             0203     12.1702      748.08      240.33      149.62
                 of nerve.
64605.........  Injection treatment   ......  T             0203     12.1702      748.08      240.33      149.62
                 of nerve.
64610.........  Injection treatment   ......  T             0203     12.1702      748.08      240.33      149.62
                 of nerve.
64612.........  Destroy nerve, face   ......  T             0204      2.2614      139.00       40.13       27.80
                 muscle.
64613.........  Destroy nerve, neck   ......  T             0204      2.2614      139.00       40.13       27.80
                 muscle.
64614.........  Destroy nerve,        ......  T             0204      2.2614      139.00       40.13       27.80
                 extrem musc.
64620.........  Injection treatment   ......  T             0203     12.1702      748.08      240.33      149.62
                 of nerve.
64622.........  Destr paravertebrl    ......  T             0203     12.1702      748.08      240.33      149.62
                 nerve l/s.
64623.........  Destr paravertebral   ......  T             0207      6.3603      390.95       86.92       78.19
                 n add-on.
64626.........  Destr paravertebrl    ......  T             0203     12.1702      748.08      240.33      149.62
                 nerve c/t.
64627.........  Destr paravertebral   ......  T             0207      6.3603      390.95       86.92       78.19
                 n add-on.
64630.........  Injection treatment   ......  T             0206      5.7253      351.92       75.55       70.38
                 of nerve.
64640.........  Injection treatment   ......  T             0206      5.7253      351.92       75.55       70.38
                 of nerve.
64650.........  Chemodenerv eccrine   ......  T             0204      2.2614      139.00       40.13       27.80
                 glands.
64653.........  Chemodenerv eccrine   ......  T             0204      2.2614      139.00       40.13       27.80
                 glands.
64680.........  Injection treatment   ......  T             0207      6.3603      390.95       86.92       78.19
                 of nerve.
64681.........  Injection treatment   ......  T             0203     12.1702      748.08      240.33      149.62
                 of nerve.
64702.........  Revise finger/toe     ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64704.........  Revise hand/foot      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64708.........  Revise arm/leg nerve  ......  T             0220     17.8499    1,097.20  ..........      219.44
64712.........  Revision of sciatic   ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64713.........  Revision of arm       ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve(s).
64714.........  Revise low back       ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve(s).
64716.........  Revision of cranial   ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64718.........  Revise ulnar nerve    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 at elbow.
64719.........  Revise ulnar nerve    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 at wrist.
64721.........  Carpal tunnel         ......  T             0220     17.8499    1,097.20  ..........      219.44
                 surgery.
64722.........  Relieve pressure on   ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve(s).
64726.........  Release foot/toe      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64727.........  Internal nerve        ......  T             0220     17.8499    1,097.20  ..........      219.44
                 revision.
64732.........  Incision of brow      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64734.........  Incision of cheek     ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64736.........  Incision of chin      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64738.........  Incision of jaw       ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64740.........  Incision of tongue    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64742.........  Incision of facial    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64744.........  Incise nerve, back    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 of head.
64746.........  Incise diaphragm      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64761.........  Incision of pelvis    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64763.........  Incise hip/thigh      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64766.........  Incise hip/thigh      ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64771.........  Sever cranial nerve.  ......  T             0220     17.8499    1,097.20  ..........      219.44
64772.........  Incision of spinal    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerve.
64774.........  Remove skin nerve     ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
64776.........  Remove digit nerve    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
64778.........  Digit nerve surgery   ......  T             0220     17.8499    1,097.20  ..........      219.44
                 add-on.

[[Page 68336]]

 
64782.........  Remove limb nerve     ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
64783.........  Limb nerve surgery    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 add-on.
64784.........  Remove nerve lesion.  ......  T             0220     17.8499    1,097.20  ..........      219.44
64786.........  Remove sciatic nerve  ......  T             0221      33.152    2,037.79      463.62      407.56
                 lesion.
64787.........  Implant nerve end...  ......  T             0220     17.8499    1,097.20  ..........      219.44
64788.........  Remove skin nerve     ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
64790.........  Removal of nerve      ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lesion.
64792.........  Removal of nerve      ......  T             0221      33.152    2,037.79      463.62      407.56
                 lesion.
64795.........  Biopsy of nerve.....  ......  T             0220     17.8499    1,097.20  ..........      219.44
64802.........  Remove sympathetic    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerves.
64804.........  Remove sympathetic     CH...  T             0220     17.8499    1,097.20  ..........      219.44
                 nerves.
64820.........  Remove sympathetic    ......  T             0220     17.8499    1,097.20  ..........      219.44
                 nerves.
64821.........  Remove sympathetic    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 nerves.
64822.........  Remove sympathetic    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 nerves.
64823.........  Remove sympathetic    ......  T             0054     25.8758    1,590.53  ..........      318.11
                 nerves.
64831.........  Repair of digit       ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64832.........  Repair nerve add-on.  ......  T             0221      33.152    2,037.79      463.62      407.56
64834.........  Repair of hand or     ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot nerve.
64835.........  Repair of hand or     ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot nerve.
64836.........  Repair of hand or     ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot nerve.
64837.........  Repair nerve add-on.  ......  T             0221      33.152    2,037.79      463.62      407.56
64840.........  Repair of leg nerve.  ......  T             0221      33.152    2,037.79      463.62      407.56
64856.........  Repair/transpose      ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64857.........  Repair arm/leg nerve  ......  T             0221      33.152    2,037.79      463.62      407.56
64858.........  Repair sciatic nerve  ......  T             0221      33.152    2,037.79      463.62      407.56
64859.........  Nerve surgery.......  ......  T             0221      33.152    2,037.79      463.62      407.56
64861.........  Repair of arm nerves  ......  T             0221      33.152    2,037.79      463.62      407.56
64862.........  Repair of low back    ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerves.
64864.........  Repair of facial      ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64865.........  Repair of facial      ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64870.........  Fusion of facial/     ......  T             0221      33.152    2,037.79      463.62      407.56
                 other nerve.
64872.........  Subsequent repair of  ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve.
64874.........  Repair & revise       ......  T             0221      33.152    2,037.79      463.62      407.56
                 nerve add-on.
64876.........  Repair nerve/shorten  ......  T             0221      33.152    2,037.79      463.62      407.56
                 bone.
64885.........  Nerve graft, head or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 neck.
64886.........  Nerve graft, head or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 neck.
64890.........  Nerve graft, hand or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot.
64891.........  Nerve graft, hand or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot.
64892.........  Nerve graft, arm or   ......  T             0221      33.152    2,037.79      463.62      407.56
                 leg.
64893.........  Nerve graft, arm or   ......  T             0221      33.152    2,037.79      463.62      407.56
                 leg.
64895.........  Nerve graft, hand or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot.
64896.........  Nerve graft, hand or  ......  T             0221      33.152    2,037.79      463.62      407.56
                 foot.
64897.........  Nerve graft, arm or   ......  T             0221      33.152    2,037.79      463.62      407.56
                 leg.
64898.........  Nerve graft, arm or   ......  T             0221      33.152    2,037.79      463.62      407.56
                 leg.
64901.........  Nerve graft add-on..  ......  T             0221      33.152    2,037.79      463.62      407.56
64902.........  Nerve graft add-on..  ......  T             0221      33.152    2,037.79      463.62      407.56
64905.........  Nerve pedicle         ......  T             0221      33.152    2,037.79      463.62      407.56
                 transfer.
64907.........  Nerve pedicle         ......  T             0221      33.152    2,037.79      463.62      407.56
                 transfer.
64910.........  Nerve repair w/        NI...  T             0220     17.8499    1,097.20  ..........      219.44
                 allograft.
64911.........  Neurorraphy w/vein     NI...  T             0220     17.8499    1,097.20  ..........      219.44
                 autograft.
64999.........  Nervous system        ......  T             0204      2.2614      139.00       40.13       27.80
                 surgery.
65091.........  Revise eye..........  ......  T             0242     35.2292    2,165.47      597.36      433.09
65093.........  Revise eye with        CH...  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
65101.........  Removal of eye......  ......  T             0242     35.2292    2,165.47      597.36      433.09
65103.........  Remove eye/insert     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
65105.........  Remove eye/attach     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
65110.........  Removal of eye......  ......  T             0242     35.2292    2,165.47      597.36      433.09
65112.........  Remove eye/revise     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
65114.........  Remove eye/revise     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
65125.........  Revise ocular         ......  T             0240     17.1243    1,052.60      309.52      210.52
                 implant.
65130.........  Insert ocular         ......  T             0241      25.255    1,552.37      384.47      310.47
                 implant.
65135.........  Insert ocular         ......  T             0241      25.255    1,552.37      384.47      310.47
                 implant.
65140.........  Attach ocular         ......  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
65150.........  Revise ocular         ......  T             0241      25.255    1,552.37      384.47      310.47
                 implant.
65155.........  Reinsert ocular       ......  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
65175.........  Removal of ocular     ......  T             0240     17.1243    1,052.60      309.52      210.52
                 implant.
65205.........  Remove foreign body   ......  S             0698      1.1607       71.35  ..........       14.27
                 from eye.
65210.........  Remove foreign body   ......  S             0698      1.1607       71.35  ..........       14.27
                 from eye.
65220.........  Remove foreign body   ......  S             0698      1.1607       71.35  ..........       14.27
                 from eye.
65222.........  Remove foreign body   ......  S             0698      1.1607       71.35  ..........       14.27
                 from eye.

[[Page 68337]]

 
65235.........  Remove foreign body   ......  T             0233     15.2259      935.91      266.33      187.18
                 from eye.
65260.........  Remove foreign body   ......  T             0236     16.5239    1,015.69  ..........      203.14
                 from eye.
65265.........  Remove foreign body   ......  T             0237      27.602    1,696.64  ..........      339.33
                 from eye.
65270.........  Repair of eye wound.  ......  T             0240     17.1243    1,052.60      309.52      210.52
65272.........  Repair of eye wound.  ......  T             0234      22.997    1,413.58      511.31      282.72
65275.........  Repair of eye wound.  ......  T             0234      22.997    1,413.58      511.31      282.72
65280.........  Repair of eye wound.  ......  T             0236     16.5239    1,015.69  ..........      203.14
65285.........  Repair of eye wound.  ......  T             0672      37.429    2,300.69  ..........      460.14
65286.........  Repair of eye wound.  ......  T             0232      6.0673      372.94       93.43       74.59
65290.........  Repair of eye socket  ......  T             0243     21.2801    1,308.05      430.35      261.61
                 wound.
65400.........  Removal of eye        ......  T             0233     15.2259      935.91      266.33      187.18
                 lesion.
65410.........  Biopsy of cornea....  ......  T             0233     15.2259      935.91      266.33      187.18
65420.........  Removal of eye        ......  T             0233     15.2259      935.91      266.33      187.18
                 lesion.
65426.........  Removal of eye        ......  T             0234      22.997    1,413.58      511.31      282.72
                 lesion.
65430.........  Corneal smear.......  ......  S             0698      1.1607       71.35  ..........       14.27
65435.........  Curette/treat cornea  ......  T             0239      7.2819      447.60  ..........       89.52
65436.........  Curette/treat cornea  ......  T             0233     15.2259      935.91      266.33      187.18
65450.........  Treatment of corneal  ......  S             0231      2.1451      131.86  ..........       26.37
                 lesion.
65600.........  Revision of cornea..  ......  T             0240     17.1243    1,052.60      309.52      210.52
65710.........  Corneal transplant..  ......  T             0244     38.2707    2,352.42      803.26      470.48
65730.........  Corneal transplant..  ......  T             0244     38.2707    2,352.42      803.26      470.48
65750.........  Corneal transplant..  ......  T             0244     38.2707    2,352.42      803.26      470.48
65755.........  Corneal transplant..  ......  T             0244     38.2707    2,352.42      803.26      470.48
65770.........  Revise cornea with     CH...  T             0293     51.9894    3,195.68    1,128.29      639.14
                 implant.
65772.........  Correction of         ......  T             0233     15.2259      935.91      266.33      187.18
                 astigmatism.
65775.........  Correction of         ......  T             0233     15.2259      935.91      266.33      187.18
                 astigmatism.
65780.........  Ocular reconst,       ......  T             0244     38.2707    2,352.42      803.26      470.48
                 transplant.
65781.........  Ocular reconst,       ......  T             0244     38.2707    2,352.42      803.26      470.48
                 transplant.
65782.........  Ocular reconst,       ......  T             0244     38.2707    2,352.42      803.26      470.48
                 transplant.
65800.........  Drainage of eye.....  ......  T             0233     15.2259      935.91      266.33      187.18
65805.........  Drainage of eye.....  ......  T             0233     15.2259      935.91      266.33      187.18
65810.........  Drainage of eye.....  ......  T             0234      22.997    1,413.58      511.31      282.72
65815.........  Drainage of eye.....  ......  T             0234      22.997    1,413.58      511.31      282.72
65820.........  Relieve inner eye     ......  T             0232      6.0673      372.94       93.43       74.59
                 pressure.
65850.........  Incision of eye.....  ......  T             0234      22.997    1,413.58      511.31      282.72
65855.........  Laser surgery of eye  ......  T             0247      5.0839      312.50      104.31       62.50
65860.........  Incise inner eye      ......  T             0247      5.0839      312.50      104.31       62.50
                 adhesions.
65865.........  Incise inner eye      ......  T             0233     15.2259      935.91      266.33      187.18
                 adhesions.
65870.........  Incise inner eye      ......  T             0234      22.997    1,413.58      511.31      282.72
                 adhesions.
65875.........  Incise inner eye      ......  T             0234      22.997    1,413.58      511.31      282.72
                 adhesions.
65880.........  Incise inner eye      ......  T             0233     15.2259      935.91      266.33      187.18
                 adhesions.
65900.........  Remove eye lesion...  ......  T             0233     15.2259      935.91      266.33      187.18
65920.........  Remove implant of     ......  T             0234      22.997    1,413.58      511.31      282.72
                 eye.
65930.........  Remove blood clot     ......  T             0234      22.997    1,413.58      511.31      282.72
                 from eye.
66020.........  Injection treatment   ......  T             0233     15.2259      935.91      266.33      187.18
                 of eye.
66030.........  Injection treatment   ......  T             0232      6.0673      372.94       93.43       74.59
                 of eye.
66130.........  Remove eye lesion...  ......  T             0234      22.997    1,413.58      511.31      282.72
66150.........  Glaucoma surgery....  ......  T             0234      22.997    1,413.58      511.31      282.72
66155.........  Glaucoma surgery....  ......  T             0234      22.997    1,413.58      511.31      282.72
66160.........  Glaucoma surgery....  ......  T             0234      22.997    1,413.58      511.31      282.72
66165.........  Glaucoma surgery....  ......  T             0234      22.997    1,413.58      511.31      282.72
66170.........  Glaucoma surgery....  ......  T             0234      22.997    1,413.58      511.31      282.72
66172.........  Incision of eye.....   CH...  T             0234      22.997    1,413.58      511.31      282.72
66180.........  Implant eye shunt...  ......  T             0673     37.8967    2,329.43      649.56      465.89
66185.........  Revise eye shunt....  ......  T             0673     37.8967    2,329.43      649.56      465.89
66220.........  Repair eye lesion...  ......  T             0672      37.429    2,300.69  ..........      460.14
66225.........  Repair/graft eye      ......  T             0673     37.8967    2,329.43      649.56      465.89
                 lesion.
66250.........  Follow-up surgery of  ......  T             0233     15.2259      935.91      266.33      187.18
                 eye.
66500.........  Incision of iris....  ......  T             0232      6.0673      372.94       93.43       74.59
66505.........  Incision of iris....  ......  T             0232      6.0673      372.94       93.43       74.59
66600.........  Remove iris and       ......  T             0234      22.997    1,413.58      511.31      282.72
                 lesion.
66605.........  Removal of iris.....  ......  T             0234      22.997    1,413.58      511.31      282.72
66625.........  Removal of iris.....  ......  T             0232      6.0673      372.94       93.43       74.59
66630.........  Removal of iris.....  ......  T             0234      22.997    1,413.58      511.31      282.72
66635.........  Removal of iris.....  ......  T             0234      22.997    1,413.58      511.31      282.72
66680.........  Repair iris &         ......  T             0234      22.997    1,413.58      511.31      282.72
                 ciliary body.
66682.........  Repair iris &         ......  T             0234      22.997    1,413.58      511.31      282.72
                 ciliary body.
66700.........  Destruction, ciliary  ......  T             0233     15.2259      935.91      266.33      187.18
                 body.
66710.........  Ciliary transsleral   ......  T             0233     15.2259      935.91      266.33      187.18
                 therapy.
66711.........  Ciliary endoscopic    ......  T             0233     15.2259      935.91      266.33      187.18
                 ablation.

[[Page 68338]]

 
66720.........  Destruction, ciliary  ......  T             0233     15.2259      935.91      266.33      187.18
                 body.
66740.........  Destruction, ciliary  ......  T             0234      22.997    1,413.58      511.31      282.72
                 body.
66761.........  Revision of iris....  ......  T             0247      5.0839      312.50      104.31       62.50
66762.........  Revision of iris....  ......  T             0247      5.0839      312.50      104.31       62.50
66770.........  Removal of inner eye  ......  T             0247      5.0839      312.50      104.31       62.50
                 lesion.
66820.........  Incision, secondary   ......  T             0232      6.0673      372.94       93.43       74.59
                 cataract.
66821.........  After cataract laser  ......  T             0247      5.0839      312.50      104.31       62.50
                 surgery.
66825.........  Reposition            ......  T             0234      22.997    1,413.58      511.31      282.72
                 intraocular lens.
66830.........  Removal of lens       ......  T             0232      6.0673      372.94       93.43       74.59
                 lesion.
66840.........  Removal of lens       ......  T             0245     14.8702      914.04      217.05      182.81
                 material.
66850.........  Removal of lens       ......  T             0249     29.2281    1,796.59      524.67      359.32
                 material.
66852.........  Removal of lens       ......  T             0249     29.2281    1,796.59      524.67      359.32
                 material.
66920.........  Extraction of lens..  ......  T             0249     29.2281    1,796.59      524.67      359.32
66930.........  Extraction of lens..  ......  T             0249     29.2281    1,796.59      524.67      359.32
66940.........  Extraction of lens..  ......  T             0245     14.8702      914.04      217.05      182.81
66982.........  Cataract surgery,     ......  T             0246     23.6313    1,452.57      495.96      290.51
                 complex.
66983.........  Cataract surg w/iol,  ......  T             0246     23.6313    1,452.57      495.96      290.51
                 1 stage.
66984.........  Cataract surg w/iol,  ......  T             0246     23.6313    1,452.57      495.96      290.51
                 1 stage.
66985.........  Insert lens           ......  T             0246     23.6313    1,452.57      495.96      290.51
                 prosthesis.
66986.........  Exchange lens         ......  T             0246     23.6313    1,452.57      495.96      290.51
                 prosthesis.
66990.........  Ophthalmic endoscope  ......  N       ..........  ..........  ..........  ..........  ..........
                 add-on.
66999.........  Eye surgery           ......  T             0232      6.0673      372.94       93.43       74.59
                 procedure.
67005.........  Partial removal of    ......  T             0237      27.602    1,696.64  ..........      339.33
                 eye fluid.
67010.........  Partial removal of    ......  T             0237      27.602    1,696.64  ..........      339.33
                 eye fluid.
67015.........  Release of eye fluid  ......  T             0237      27.602    1,696.64  ..........      339.33
67025.........  Replace eye fluid...  ......  T             0237      27.602    1,696.64  ..........      339.33
67027.........  Implant eye drug      ......  T             0672      37.429    2,300.69  ..........      460.14
                 system.
67028.........  Injection eye drug..  ......  T             0235      3.9333      241.77       58.93       48.35
67030.........  Incise inner eye      ......  T             0236     16.5239    1,015.69  ..........      203.14
                 strands.
67031.........  Laser surgery, eye    ......  T             0247      5.0839      312.50      104.31       62.50
                 strands.
67036.........  Removal of inner eye  ......  T             0672      37.429    2,300.69  ..........      460.14
                 fluid.
67038.........  Strip retinal         ......  T             0672      37.429    2,300.69  ..........      460.14
                 membrane.
67039.........  Laser treatment of    ......  T             0672      37.429    2,300.69  ..........      460.14
                 retina.
67040.........  Laser treatment of    ......  T             0672      37.429    2,300.69  ..........      460.14
                 retina.
67101.........  Repair detached       ......  T             0236     16.5239    1,015.69  ..........      203.14
                 retina.
67105.........  Repair detached       ......  T             0248      5.0841      312.51       95.08       62.50
                 retina.
67107.........  Repair detached       ......  T             0672      37.429    2,300.69  ..........      460.14
                 retina.
67108.........  Repair detached       ......  T             0672      37.429    2,300.69  ..........      460.14
                 retina.
67110.........  Repair detached       ......  T             0236     16.5239    1,015.69  ..........      203.14
                 retina.
67112.........  Rerepair detached     ......  T             0672      37.429    2,300.69  ..........      460.14
                 retina.
67115.........  Release encircling    ......  T             0236     16.5239    1,015.69  ..........      203.14
                 material.
67120.........  Remove eye implant    ......  T             0236     16.5239    1,015.69  ..........      203.14
                 material.
67121.........  Remove eye implant    ......  T             0237      27.602    1,696.64  ..........      339.33
                 material.
67141.........  Treatment of retina.  ......  T             0235      3.9333      241.77       58.93       48.35
67145.........  Treatment of retina.  ......  T             0248      5.0841      312.51       95.08       62.50
67208.........  Treatment of retinal  ......  T             0236     16.5239    1,015.69  ..........      203.14
                 lesion.
67210.........  Treatment of retinal  ......  T             0248      5.0841      312.51       95.08       62.50
                 lesion.
67218.........  Treatment of retinal  ......  T             0236     16.5239    1,015.69  ..........      203.14
                 lesion.
67220.........  Treatment of choroid  ......  T             0235      3.9333      241.77       58.93       48.35
                 lesion.
67221.........  Ocular photodynamic   ......  T             0235      3.9333      241.77       58.93       48.35
                 ther.
67225.........  Eye photodynamic      ......  T             0235      3.9333      241.77       58.93       48.35
                 ther add-on.
67227.........  Treatment of retinal   CH...  T             0237      27.602    1,696.64  ..........      339.33
                 lesion.
67228.........  Treatment of retinal  ......  T             0248      5.0841      312.51       95.08       62.50
                 lesion.
67250.........  Reinforce eye wall..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67255.........  Reinforce/graft eye   ......  T             0237      27.602    1,696.64  ..........      339.33
                 wall.
67299.........  Eye surgery           ......  T             0235      3.9333      241.77       58.93       48.35
                 procedure.
67311.........  Revise eye muscle...  ......  T             0243     21.2801    1,308.05      430.35      261.61
67312.........  Revise two eye        ......  T             0243     21.2801    1,308.05      430.35      261.61
                 muscles.
67314.........  Revise eye muscle...  ......  T             0243     21.2801    1,308.05      430.35      261.61
67316.........  Revise two eye        ......  T             0243     21.2801    1,308.05      430.35      261.61
                 muscles.
67318.........  Revise eye muscle(s)  ......  T             0243     21.2801    1,308.05      430.35      261.61
67320.........  Revise eye muscle(s)  ......  T             0243     21.2801    1,308.05      430.35      261.61
                 add-on.
67331.........  Eye surgery follow-   ......  T             0243     21.2801    1,308.05      430.35      261.61
                 up add-on.
67332.........  Rerevise eye muscles  ......  T             0243     21.2801    1,308.05      430.35      261.61
                 add-on.
67334.........  Revise eye muscle w/  ......  T             0243     21.2801    1,308.05      430.35      261.61
                 suture.
67335.........  Eye suture during     ......  T             0243     21.2801    1,308.05      430.35      261.61
                 surgery.
67340.........  Revise eye muscle     ......  T             0243     21.2801    1,308.05      430.35      261.61
                 add-on.
67343.........  Release eye tissue..  ......  T             0243     21.2801    1,308.05      430.35      261.61
67345.........  Destroy nerve of eye  ......  T             0238      2.8954      177.97  ..........       35.59
                 muscle.
67346.........  Biopsy, eye muscle..   NI...  T             0699     14.3845      884.19  ..........      176.84

[[Page 68339]]

 
67350.........  Biopsy eye muscle...   CH...  D       ..........  ..........  ..........  ..........  ..........
67399.........  Eye muscle surgery    ......  T             0243     21.2801    1,308.05      430.35      261.61
                 procedure.
67400.........  Explore/biopsy eye    ......  T             0241      25.255    1,552.37      384.47      310.47
                 socket.
67405.........  Explore/drain eye     ......  T             0241      25.255    1,552.37      384.47      310.47
                 socket.
67412.........  Explore/treat eye     ......  T             0241      25.255    1,552.37      384.47      310.47
                 socket.
67413.........  Explore/treat eye     ......  T             0241      25.255    1,552.37      384.47      310.47
                 socket.
67414.........  Explr/decompress eye  ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67415.........  Aspiration, orbital   ......  T             0240     17.1243    1,052.60      309.52      210.52
                 contents.
67420.........  Explore/treat eye     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67430.........  Explore/treat eye     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67440.........  Explore/drain eye     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67445.........  Explr/decompress eye  ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67450.........  Explore/biopsy eye    ......  T             0242     35.2292    2,165.47      597.36      433.09
                 socket.
67500.........  Inject/treat eye      ......  S             0231      2.1451      131.86  ..........       26.37
                 socket.
67505.........  Inject/treat eye      ......  T             0238      2.8954      177.97  ..........       35.59
                 socket.
67515.........  Inject/treat eye      ......  T             0238      2.8954      177.97  ..........       35.59
                 socket.
67550.........  Insert eye socket     ......  T             0242     35.2292    2,165.47      597.36      433.09
                 implant.
67560.........  Revise eye socket     ......  T             0241      25.255    1,552.37      384.47      310.47
                 implant.
67570.........  Decompress optic      ......  T             0242     35.2292    2,165.47      597.36      433.09
                 nerve.
67599.........  Orbit surgery         ......  T             0238      2.8954      177.97  ..........       35.59
                 procedure.
67700.........  Drainage of eyelid    ......  T             0238      2.8954      177.97  ..........       35.59
                 abscess.
67710.........  Incision of eyelid..  ......  T             0239      7.2819      447.60  ..........       89.52
67715.........  Incision of eyelid    ......  T             0240     17.1243    1,052.60      309.52      210.52
                 fold.
67800.........  Remove eyelid lesion  ......  T             0238      2.8954      177.97  ..........       35.59
67801.........  Remove eyelid         ......  T             0239      7.2819      447.60  ..........       89.52
                 lesions.
67805.........  Remove eyelid         ......  T             0238      2.8954      177.97  ..........       35.59
                 lesions.
67808.........  Remove eyelid         ......  T             0240     17.1243    1,052.60      309.52      210.52
                 lesion(s).
67810.........  Biopsy of eyelid....  ......  T             0238      2.8954      177.97  ..........       35.59
67820.........  Revise eyelashes....  ......  S             0698      1.1607       71.35  ..........       14.27
67825.........  Revise eyelashes....  ......  T             0238      2.8954      177.97  ..........       35.59
67830.........  Revise eyelashes....  ......  T             0239      7.2819      447.60  ..........       89.52
67835.........  Revise eyelashes....  ......  T             0240     17.1243    1,052.60      309.52      210.52
67840.........  Remove eyelid lesion  ......  T             0239      7.2819      447.60  ..........       89.52
67850.........  Treat eyelid lesion.  ......  T             0239      7.2819      447.60  ..........       89.52
67875.........  Closure of eyelid by  ......  T             0239      7.2819      447.60  ..........       89.52
                 suture.
67880.........  Revision of eyelid..  ......  T             0233     15.2259      935.91      266.33      187.18
67882.........  Revision of eyelid..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67900.........  Repair brow defect..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67901.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67902.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67903.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67904.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67906.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67908.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67909.........  Revise eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67911.........  Revise eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67912.........  Correction eyelid w/  ......  T             0240     17.1243    1,052.60      309.52      210.52
                 implant.
67914.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67915.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67916.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67917.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67921.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67922.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67923.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67924.........  Repair eyelid defect  ......  T             0240     17.1243    1,052.60      309.52      210.52
67930.........  Repair eyelid wound.  ......  T             0240     17.1243    1,052.60      309.52      210.52
67935.........  Repair eyelid wound.  ......  T             0240     17.1243    1,052.60      309.52      210.52
67938.........  Remove eyelid         ......  S             0698      1.1607       71.35  ..........       14.27
                 foreign body.
67950.........  Revision of eyelid..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67961.........  Revision of eyelid..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67966.........  Revision of eyelid..  ......  T             0240     17.1243    1,052.60      309.52      210.52
67971.........  Reconstruction of     ......  T             0241      25.255    1,552.37      384.47      310.47
                 eyelid.
67973.........  Reconstruction of     ......  T             0241      25.255    1,552.37      384.47      310.47
                 eyelid.
67974.........  Reconstruction of     ......  T             0241      25.255    1,552.37      384.47      310.47
                 eyelid.
67975.........  Reconstruction of     ......  T             0240     17.1243    1,052.60      309.52      210.52
                 eyelid.
67999.........  Revision of eyelid..  ......  T             0238      2.8954      177.97  ..........       35.59
68020.........  Incise/drain eyelid   ......  T             0240     17.1243    1,052.60      309.52      210.52
                 lining.
68040.........  Treatment of eyelid   ......  S             0698      1.1607       71.35  ..........       14.27
                 lesions.
68100.........  Biopsy of eyelid      ......  T             0232      6.0673      372.94       93.43       74.59
                 lining.
68110.........  Remove eyelid lining  ......  T             0699     14.3845      884.19  ..........      176.84
                 lesion.

[[Page 68340]]

 
68115.........  Remove eyelid lining  ......  T             0240     17.1243    1,052.60      309.52      210.52
                 lesion.
68130.........  Remove eyelid lining  ......  T             0233     15.2259      935.91      266.33      187.18
                 lesion.
68135.........  Remove eyelid lining  ......  T             0239      7.2819      447.60  ..........       89.52
                 lesion.
68200.........  Treat eyelid by       ......  S             0230      0.7898       48.55       14.97        9.71
                 injection.
68320.........  Revise/graft eyelid   ......  T             0240     17.1243    1,052.60      309.52      210.52
                 lining.
68325.........  Revise/graft eyelid    CH...  T             0241      25.255    1,552.37      384.47      310.47
                 lining.
68326.........  Revise/graft eyelid   ......  T             0241      25.255    1,552.37      384.47      310.47
                 lining.
68328.........  Revise/graft eyelid   ......  T             0241      25.255    1,552.37      384.47      310.47
                 lining.
68330.........  Revise eyelid lining  ......  T             0234      22.997    1,413.58      511.31      282.72
68335.........  Revise/graft eyelid   ......  T             0241      25.255    1,552.37      384.47      310.47
                 lining.
68340.........  Separate eyelid       ......  T             0240     17.1243    1,052.60      309.52      210.52
                 adhesions.
68360.........  Revise eyelid lining  ......  T             0234      22.997    1,413.58      511.31      282.72
68362.........  Revise eyelid lining  ......  T             0234      22.997    1,413.58      511.31      282.72
68371.........  Harvest eye tissue,   ......  T             0233     15.2259      935.91      266.33      187.18
                 alograft.
68399.........  Eyelid lining         ......  T             0238      2.8954      177.97  ..........       35.59
                 surgery.
68400.........  Incise/drain tear     ......  T             0238      2.8954      177.97  ..........       35.59
                 gland.
68420.........  Incise/drain tear     ......  T             0240     17.1243    1,052.60      309.52      210.52
                 sac.
68440.........  Incise tear duct      ......  T             0238      2.8954      177.97  ..........       35.59
                 opening.
68500.........  Removal of tear       ......  T             0241      25.255    1,552.37      384.47      310.47
                 gland.
68505.........  Partial removal,      ......  T             0241      25.255    1,552.37      384.47      310.47
                 tear gland.
68510.........  Biopsy of tear gland  ......  T             0240     17.1243    1,052.60      309.52      210.52
68520.........  Removal of tear sac.  ......  T             0241      25.255    1,552.37      384.47      310.47
68525.........  Biopsy of tear sac..  ......  T             0240     17.1243    1,052.60      309.52      210.52
68530.........  Clearance of tear     ......  T             0240     17.1243    1,052.60      309.52      210.52
                 duct.
68540.........  Remove tear gland     ......  T             0241      25.255    1,552.37      384.47      310.47
                 lesion.
68550.........  Remove tear gland      CH...  T             0241      25.255    1,552.37      384.47      310.47
                 lesion.
68700.........  Repair tear ducts...  ......  T             0241      25.255    1,552.37      384.47      310.47
68705.........  Revise tear duct      ......  T             0238      2.8954      177.97  ..........       35.59
                 opening.
68720.........  Create tear sac        CH...  T             0241      25.255    1,552.37      384.47      310.47
                 drain.
68745.........  Create tear duct      ......  T             0241      25.255    1,552.37      384.47      310.47
                 drain.
68750.........  Create tear duct       CH...  T             0241      25.255    1,552.37      384.47      310.47
                 drain.
68760.........  Close tear duct        CH...  S             0231      2.1451      131.86  ..........       26.37
                 opening.
68761.........  Close tear duct       ......  S             0231      2.1451      131.86  ..........       26.37
                 opening.
68770.........  Close tear system     ......  T             0240     17.1243    1,052.60      309.52      210.52
                 fistula.
68801.........  Dilate tear duct      ......  S             0698      1.1607       71.35  ..........       14.27
                 opening.
68810.........  Probe nasolacrimal    ......  S             0231      2.1451      131.86  ..........       26.37
                 duct.
68811.........  Probe nasolacrimal    ......  T             0240     17.1243    1,052.60      309.52      210.52
                 duct.
68815.........  Probe nasolacrimal    ......  T             0240     17.1243    1,052.60      309.52      210.52
                 duct.
68840.........  Explore/irrigate       CH...  S             0698      1.1607       71.35  ..........       14.27
                 tear ducts.
68850.........  Injection for tear    ......  N       ..........  ..........  ..........  ..........  ..........
                 sac x-ray.
68899.........  Tear duct system       CH...  T             0238      2.8954      177.97  ..........       35.59
                 surgery.
69000.........  Drain external ear    ......  T             0006      1.4392       88.46  ..........       17.69
                 lesion.
69005.........  Drain external ear    ......  T             0008     17.5086    1,076.22  ..........      215.24
                 lesion.
69020.........  Drain outer ear       ......  T             0006      1.4392       88.46  ..........       17.69
                 canal lesion.
69100.........  Biopsy of external    ......  T             0019      4.0919      251.52       71.87       50.30
                 ear.
69105.........  Biopsy of external    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 ear canal.
69110.........  Remove external ear,  ......  T             0021     15.1024      928.31      219.48      185.66
                 partial.
69120.........  Removal of external   ......  T             0254     23.3299    1,434.04      321.35      286.81
                 ear.
69140.........  Remove ear canal      ......  T             0254     23.3299    1,434.04      321.35      286.81
                 lesion(s).
69145.........  Remove ear canal      ......  T             0021     15.1024      928.31      219.48      185.66
                 lesion(s).
69150.........  Extensive ear canal   ......  T             0252      7.5511      464.15      109.16       92.83
                 surgery.
69200.........  Clear outer ear       ......  X             0340      0.6102       37.51  ..........        7.50
                 canal.
69205.........  Clear outer ear       ......  T             0022     20.0656    1,233.39      354.45      246.68
                 canal.
69210.........  Remove impacted ear   ......  X             0340      0.6102       37.51  ..........        7.50
                 wax.
69220.........  Clean out mastoid     ......  T             0012      0.8432       51.83       11.18       10.37
                 cavity.
69222.........  Clean out mastoid      CH...  T             0252      7.5511      464.15      109.16       92.83
                 cavity.
69300.........  Revise external ear.  ......  T             0254     23.3299    1,434.04      321.35      286.81
69310.........  Rebuild outer ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 canal.
69320.........  Rebuild outer ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 canal.
69399.........  Outer ear surgery     ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
69400.........  Inflate middle ear    ......  T             0251       2.452      150.72  ..........       30.14
                 canal.
69401.........  Inflate middle ear    ......  T             0251       2.452      150.72  ..........       30.14
                 canal.
69405.........  Catheterize middle    ......  T             0252      7.5511      464.15      109.16       92.83
                 ear canal.
69420.........  Incision of eardrum.  ......  T             0251       2.452      150.72  ..........       30.14
69421.........  Incision of eardrum.  ......  T             0253     16.4266    1,009.71      282.29      201.94
69424.........  Remove ventilating    ......  T             0252      7.5511      464.15      109.16       92.83
                 tube.
69433.........  Create eardrum        ......  T             0252      7.5511      464.15      109.16       92.83
                 opening.
69436.........  Create eardrum        ......  T             0253     16.4266    1,009.71      282.29      201.94
                 opening.
69440.........  Exploration of        ......  T             0254     23.3299    1,434.04      321.35      286.81
                 middle ear.
69450.........  Eardrum revision....  ......  T             0256     38.1991    2,348.02  ..........      469.60

[[Page 68341]]

 
69501.........  Mastoidectomy.......  ......  T             0256     38.1991    2,348.02  ..........      469.60
69502.........  Mastoidectomy.......  ......  T             0254     23.3299    1,434.04      321.35      286.81
69505.........  Remove mastoid        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69511.........  Extensive mastoid     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 surgery.
69530.........  Extensive mastoid     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 surgery.
69540.........  Remove ear lesion...  ......  T             0253     16.4266    1,009.71      282.29      201.94
69550.........  Remove ear lesion...  ......  T             0256     38.1991    2,348.02  ..........      469.60
69552.........  Remove ear lesion...  ......  T             0256     38.1991    2,348.02  ..........      469.60
69601.........  Mastoid surgery       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69602.........  Mastoid surgery       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69603.........  Mastoid surgery       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69604.........  Mastoid surgery       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69605.........  Mastoid surgery       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69610.........  Repair of eardrum...  ......  T             0254     23.3299    1,434.04      321.35      286.81
69620.........  Repair of eardrum...  ......  T             0254     23.3299    1,434.04      321.35      286.81
69631.........  Repair eardrum        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69632.........  Rebuild eardrum       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69633.........  Rebuild eardrum       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69635.........  Repair eardrum        ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69636.........  Rebuild eardrum       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69637.........  Rebuild eardrum       ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69641.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69642.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69643.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69644.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69645.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69646.........  Revise middle ear &   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69650.........  Release middle ear    ......  T             0254     23.3299    1,434.04      321.35      286.81
                 bone.
69660.........  Revise middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bone.
69661.........  Revise middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bone.
69662.........  Revise middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 bone.
69666.........  Repair middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69667.........  Repair middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 structures.
69670.........  Remove mastoid air    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 cells.
69676.........  Remove middle ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nerve.
69700.........  Close mastoid         ......  T             0256     38.1991    2,348.02  ..........      469.60
                 fistula.
69711.........  Remove/repair         ......  T             0256     38.1991    2,348.02  ..........      469.60
                 hearing aid.
69714.........  Implant temple bone   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 w/stimul.
69715.........  Temple bne implnt w/  ......  T             0256     38.1991    2,348.02  ..........      469.60
                 stimulat.
69717.........  Temple bone implant   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 revision.
69718.........  Revise temple bone    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 implant.
69720.........  Release facial nerve  ......  T             0256     38.1991    2,348.02  ..........      469.60
69725.........  Release facial nerve  ......  T             0256     38.1991    2,348.02  ..........      469.60
69740.........  Repair facial nerve.  ......  T             0256     38.1991    2,348.02  ..........      469.60
69745.........  Repair facial nerve.  ......  T             0256     38.1991    2,348.02  ..........      469.60
69799.........  Middle ear surgery    ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
69801.........  Incise inner ear....  ......  T             0256     38.1991    2,348.02  ..........      469.60
69802.........  Incise inner ear....  ......  T             0256     38.1991    2,348.02  ..........      469.60
69805.........  Explore inner ear...  ......  T             0256     38.1991    2,348.02  ..........      469.60
69806.........  Explore inner ear...  ......  T             0256     38.1991    2,348.02  ..........      469.60
69820.........  Establish inner ear   ......  T             0256     38.1991    2,348.02  ..........      469.60
                 window.
69840.........  Revise inner ear      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 window.
69905.........  Remove inner ear....  ......  T             0256     38.1991    2,348.02  ..........      469.60
69910.........  Remove inner ear &    ......  T             0256     38.1991    2,348.02  ..........      469.60
                 mastoid.
69915.........  Incise inner ear      ......  T             0256     38.1991    2,348.02  ..........      469.60
                 nerve.
69930.........  Implant cochlear      ......  T             0259    414.8455   25,499.72    8,698.43    5,099.94
                 device.
69949.........  Inner ear surgery     ......  T             0251       2.452      150.72  ..........       30.14
                 procedure.
69955.........  Release facial nerve  ......  T             0256     38.1991    2,348.02  ..........      469.60
69960.........  Release inner ear     ......  T             0256     38.1991    2,348.02  ..........      469.60
                 canal.
69979.........  Temporal bone         ......  T             0251       2.452      150.72  ..........       30.14
                 surgery.
69990.........  Microsurgery add-on.  ......  N       ..........  ..........  ..........  ..........  ..........
70010.........  Contrast x-ray of     ......  S             0274      2.5544      157.01       62.80       31.40
                 brain.
70015.........  Contrast x-ray of     ......  S             0274      2.5544      157.01       62.80       31.40
                 brain.
70030.........  X-ray eye for         ......  X             0260      0.7093       43.60  ..........        8.72
                 foreign body.
70100.........  X-ray exam of jaw...  ......  X             0260      0.7093       43.60  ..........        8.72
70110.........  X-ray exam of jaw...  ......  X             0260      0.7093       43.60  ..........        8.72
70120.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 mastoids.
70130.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 mastoids.
70134.........  X-ray exam of middle  ......  X             0261      1.2224       75.14  ..........       15.03
                 ear.
70140.........  X-ray exam of facial  ......  X             0260      0.7093       43.60  ..........        8.72
                 bones.

[[Page 68342]]

 
70150.........  X-ray exam of facial  ......  X             0260      0.7093       43.60  ..........        8.72
                 bones.
70160.........  X-ray exam of nasal   ......  X             0260      0.7093       43.60  ..........        8.72
                 bones.
70170.........  X-ray exam of tear    ......  X             0264      2.9586      181.86       70.27       36.37
                 duct.
70190.........  X-ray exam of eye     ......  X             0260      0.7093       43.60  ..........        8.72
                 sockets.
70200.........  X-ray exam of eye     ......  X             0260      0.7093       43.60  ..........        8.72
                 sockets.
70210.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 sinuses.
70220.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 sinuses.
70240.........  X-ray exam,           ......  X             0260      0.7093       43.60  ..........        8.72
                 pituitary saddle.
70250.........  X-ray exam of skull.  ......  X             0260      0.7093       43.60  ..........        8.72
70260.........  X-ray exam of skull.  ......  X             0261      1.2224       75.14  ..........       15.03
70300.........  X-ray exam of teeth.  ......  X             0262       0.655       40.26  ..........        8.05
70310.........  X-ray exam of teeth.  ......  X             0262       0.655       40.26  ..........        8.05
70320.........  Full mouth x-ray of   ......  X             0262       0.655       40.26  ..........        8.05
                 teeth.
70328.........  X-ray exam of jaw     ......  X             0260      0.7093       43.60  ..........        8.72
                 joint.
70330.........  X-ray exam of jaw     ......  X             0260      0.7093       43.60  ..........        8.72
                 joints.
70332.........  X-ray exam of jaw     ......  S             0275      3.6915      226.91       69.09       45.38
                 joint.
70336.........  Magnetic image, jaw   ......  S             0335      4.5523      279.82      111.92       55.96
                 joint.
70350.........  X-ray head for        ......  X             0260      0.7093       43.60  ..........        8.72
                 orthodontia.
70355.........  Panoramic x-ray of    ......  X             0260      0.7093       43.60  ..........        8.72
                 jaws.
70360.........  X-ray exam of neck..  ......  X             0260      0.7093       43.60  ..........        8.72
70370.........  Throat x-ray &        ......  X             0272      1.2908       79.34       31.64       15.87
                 fluoroscopy.
70371.........  Speech evaluation,    ......  X             0272      1.2908       79.34       31.64       15.87
                 complex.
70373.........  Contrast x-ray of     ......  X             0263      1.6956      104.23       23.77       20.85
                 larynx.
70380.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 salivary gland.
70390.........  X-ray exam of         ......  X             0263      1.6956      104.23       23.77       20.85
                 salivary duct.
70450.........  Ct head/brain w/o     ......  S             0332      3.0908      189.99       75.24       38.00
                 dye.
70460.........  Ct head/brain w/dye.  ......  S             0283      4.0825      250.94      100.37       50.19
70470.........  Ct head/brain w/o &   ......  S             0333      4.8405      297.54      119.01       59.51
                 w/dye.
70480.........  Ct orbit/ear/fossa w/ ......  S             0332      3.0908      189.99       75.24       38.00
                 o dye.
70481.........  Ct orbit/ear/fossa w/ ......  S             0283      4.0825      250.94      100.37       50.19
                 dye.
70482.........  Ct orbit/ear/fossa w/ ......  S             0333      4.8405      297.54      119.01       59.51
                 o&w/dye.
70486.........  Ct maxillofacial w/o  ......  S             0332      3.0908      189.99       75.24       38.00
                 dye.
70487.........  Ct maxillofacial w/   ......  S             0283      4.0825      250.94      100.37       50.19
                 dye.
70488.........  Ct maxillofacial w/o  ......  S             0333      4.8405      297.54      119.01       59.51
                 & w/dye.
70490.........  Ct soft tissue neck   ......  S             0332      3.0908      189.99       75.24       38.00
                 w/o dye.
70491.........  Ct soft tissue neck   ......  S             0283      4.0825      250.94      100.37       50.19
                 w/dye.
70492.........  Ct sft tsue nck w/o   ......  S             0333      4.8405      297.54      119.01       59.51
                 & w/dye.
70496.........  Ct angiography, head  ......  S             0662      4.8552      298.44      118.88       59.69
70498.........  Ct angiography, neck  ......  S             0662      4.8552      298.44      118.88       59.69
70540.........  Mri orbit/face/neck   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
70542.........  Mri orbit/face/neck   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
70543.........  Mri orbt/fac/nck w/o  ......  S             0337      8.1155      498.84      199.53       99.77
                 & w/dye.
70544.........  Mr angiography head   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
70545.........  Mr angiography head   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
70546.........  Mr angiograph head w/ ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
70547.........  Mr angiography neck   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
70548.........  Mr angiography neck   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
70549.........  Mr angiograph neck w/ ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
70551.........  Mri brain w/o dye...  ......  S             0336      5.6745      348.80      139.51       69.76
70552.........  Mri brain w/dye.....  ......  S             0284      6.1231      376.37      148.40       75.27
70553.........  Mri brain w/o & w/    ......  S             0337      8.1155      498.84      199.53       99.77
                 dye.
70554.........  Fmri brain by tech..   NI...  S             0336      5.6745      348.80      139.51       69.76
70555.........  Fmri brain by phys/    NI...  S             0336      5.6745      348.80      139.51       69.76
                 psych.
70557.........  Mri brain w/o dye...  ......  S             0336      5.6745      348.80      139.51       69.76
70558.........  Mri brain w/dye.....  ......  S             0284      6.1231      376.37      148.40       75.27
70559.........  Mri brain w/o & w/    ......  S             0337      8.1155      498.84      199.53       99.77
                 dye.
71010.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71015.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71020.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71021.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71022.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71023.........  Chest x-ray and       ......  X             0272      1.2908       79.34       31.64       15.87
                 fluoroscopy.
71030.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71034.........  Chest x-ray and       ......  X             0272      1.2908       79.34       31.64       15.87
                 fluoroscopy.
71035.........  Chest x-ray.........  ......  X             0260      0.7093       43.60  ..........        8.72
71040.........  Contrast x-ray of     ......  X             0263      1.6956      104.23       23.77       20.85
                 bronchi.
71060.........  Contrast x-ray of     ......  X             0263      1.6956      104.23       23.77       20.85
                 bronchi.
71090.........  X-ray & pacemaker     ......  X             0272      1.2908       79.34       31.64       15.87
                 insertion.
71100.........  X-ray exam of ribs..  ......  X             0260      0.7093       43.60  ..........        8.72
71101.........  X-ray exam of ribs/   ......  X             0260      0.7093       43.60  ..........        8.72
                 chest.

[[Page 68343]]

 
71110.........  X-ray exam of ribs..  ......  X             0260      0.7093       43.60  ..........        8.72
71111.........  X-ray exam of ribs/   ......  X             0261      1.2224       75.14  ..........       15.03
                 chest.
71120.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 breastbone.
71130.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 breastbone.
71250.........  Ct thorax w/o dye...  ......  S             0332      3.0908      189.99       75.24       38.00
71260.........  Ct thorax w/dye.....  ......  S             0283      4.0825      250.94      100.37       50.19
71270.........  Ct thorax w/o & w/    ......  S             0333      4.8405      297.54      119.01       59.51
                 dye.
71275.........  Ct angiography,       ......  S             0662      4.8552      298.44      118.88       59.69
                 chest.
71550.........  Mri chest w/o dye...  ......  S             0336      5.6745      348.80      139.51       69.76
71551.........  Mri chest w/dye.....  ......  S             0284      6.1231      376.37      148.40       75.27
71552.........  Mri chest w/o & w/    ......  S             0337      8.1155      498.84      199.53       99.77
                 dye.
72010.........  X-ray exam of spine.  ......  X             0260      0.7093       43.60  ..........        8.72
72020.........  X-ray exam of spine.  ......  X             0260      0.7093       43.60  ..........        8.72
72040.........  X-ray exam of neck    ......  X             0260      0.7093       43.60  ..........        8.72
                 spine.
72050.........  X-ray exam of neck    ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72052.........  X-ray exam of neck    ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72069.........  X-ray exam of trunk   ......  X             0260      0.7093       43.60  ..........        8.72
                 spine.
72070.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 thoracic spine.
72072.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 thoracic spine.
72074.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 thoracic spine.
72080.........  X-ray exam of trunk   ......  X             0260      0.7093       43.60  ..........        8.72
                 spine.
72090.........  X-ray exam of trunk   ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72100.........  X-ray exam of lower   ......  X             0260      0.7093       43.60  ..........        8.72
                 spine.
72110.........  X-ray exam of lower   ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72114.........  X-ray exam of lower   ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72120.........  X-ray exam of lower   ......  X             0261      1.2224       75.14  ..........       15.03
                 spine.
72125.........  Ct neck spine w/o     ......  S             0332      3.0908      189.99       75.24       38.00
                 dye.
72126.........  Ct neck spine w/dye.  ......  S             0283      4.0825      250.94      100.37       50.19
72127.........  Ct neck spine w/o &   ......  S             0333      4.8405      297.54      119.01       59.51
                 w/dye.
72128.........  Ct chest spine w/o    ......  S             0332      3.0908      189.99       75.24       38.00
                 dye.
72129.........  Ct chest spine w/dye  ......  S             0283      4.0825      250.94      100.37       50.19
72130.........  Ct chest spine w/o &  ......  S             0333      4.8405      297.54      119.01       59.51
                 w/dye.
72131.........  Ct lumbar spine w/o   ......  S             0332      3.0908      189.99       75.24       38.00
                 dye.
72132.........  Ct lumbar spine w/    ......  S             0283      4.0825      250.94      100.37       50.19
                 dye.
72133.........  Ct lumbar spine w/o   ......  S             0333      4.8405      297.54      119.01       59.51
                 & w/dye.
72141.........  Mri neck spine w/o    ......  S             0336      5.6745      348.80      139.51       69.76
                 dye.
72142.........  Mri neck spine w/dye  ......  S             0284      6.1231      376.37      148.40       75.27
72146.........  Mri chest spine w/o   ......  S             0336      5.6745      348.80      139.51       69.76
                 dye.
72147.........  Mri chest spine w/    ......  S             0284      6.1231      376.37      148.40       75.27
                 dye.
72148.........  Mri lumbar spine w/o  ......  S             0336      5.6745      348.80      139.51       69.76
                 dye.
72149.........  Mri lumbar spine w/   ......  S             0284      6.1231      376.37      148.40       75.27
                 dye.
72156.........  Mri neck spine w/o &  ......  S             0337      8.1155      498.84      199.53       99.77
                 w/dye.
72157.........  Mri chest spine w/o   ......  S             0337      8.1155      498.84      199.53       99.77
                 & w/dye.
72158.........  Mri lumbar spine w/o  ......  S             0337      8.1155      498.84      199.53       99.77
                 & w/dye.
72170.........  X-ray exam of pelvis  ......  X             0260      0.7093       43.60  ..........        8.72
72190.........  X-ray exam of pelvis  ......  X             0260      0.7093       43.60  ..........        8.72
72191.........  Ct angiograph pelv w/ ......  S             0662      4.8552      298.44      118.88       59.69
                 o&w/dye.
72192.........  Ct pelvis w/o dye...  ......  S             0332      3.0908      189.99       75.24       38.00
72193.........  Ct pelvis w/dye.....  ......  S             0283      4.0825      250.94      100.37       50.19
72194.........  Ct pelvis w/o & w/    ......  S             0333      4.8405      297.54      119.01       59.51
                 dye.
72195.........  Mri pelvis w/o dye..  ......  S             0336      5.6745      348.80      139.51       69.76
72196.........  Mri pelvis w/dye....  ......  S             0284      6.1231      376.37      148.40       75.27
72197.........  Mri pelvis w/o & w/   ......  S             0337      8.1155      498.84      199.53       99.77
                 dye.
72200.........  X-ray exam            ......  X             0260      0.7093       43.60  ..........        8.72
                 sacroiliac joints.
72202.........  X-ray exam            ......  X             0260      0.7093       43.60  ..........        8.72
                 sacroiliac joints.
72220.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 tailbone.
72240.........  Contrast x-ray of     ......  S             0274      2.5544      157.01       62.80       31.40
                 neck spine.
72255.........  Contrast x-ray,       ......  S             0274      2.5544      157.01       62.80       31.40
                 thorax spine.
72265.........  Contrast x-ray,       ......  S             0274      2.5544      157.01       62.80       31.40
                 lower spine.
72270.........  Contrast x-ray,       ......  S             0274      2.5544      157.01       62.80       31.40
                 spine.
72275.........  Epidurography.......  ......  S             0274      2.5544      157.01       62.80       31.40
72285.........  X-ray c/t spine disk  ......  S             0388     15.9758      982.00      289.72      196.40
72291.........  Perq vertebroplasty,   NI...  S             0274      2.5544      157.01       62.80       31.40
                 fluor.
72292.........  Perq vertebroplasty,   NI...  S             0274      2.5544      157.01       62.80       31.40
                 ct.
72295.........  X-ray of lower spine  ......  S             0388     15.9758      982.00      289.72      196.40
                 disk.
73000.........  X-ray exam of collar  ......  X             0260      0.7093       43.60  ..........        8.72
                 bone.
73010.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 shoulder blade.
73020.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 shoulder.
73030.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 shoulder.
73040.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 shoulder.

[[Page 68344]]

 
73050.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 shoulders.
73060.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 humerus.
73070.........  X-ray exam of elbow.  ......  X             0260      0.7093       43.60  ..........        8.72
73080.........  X-ray exam of elbow.  ......  X             0260      0.7093       43.60  ..........        8.72
73085.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 elbow.
73090.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 forearm.
73092.........  X-ray exam of arm,    ......  X             0260      0.7093       43.60  ..........        8.72
                 infant.
73100.........  X-ray exam of wrist.  ......  X             0260      0.7093       43.60  ..........        8.72
73110.........  X-ray exam of wrist.  ......  X             0260      0.7093       43.60  ..........        8.72
73115.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 wrist.
73120.........  X-ray exam of hand..  ......  X             0260      0.7093       43.60  ..........        8.72
73130.........  X-ray exam of hand..  ......  X             0260      0.7093       43.60  ..........        8.72
73140.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 finger(s).
73200.........  Ct upper extremity w/ ......  S             0332      3.0908      189.99       75.24       38.00
                 o dye.
73201.........  Ct upper extremity w/ ......  S             0283      4.0825      250.94      100.37       50.19
                 dye.
73202.........  Ct uppr extremity w/  ......  S             0333      4.8405      297.54      119.01       59.51
                 o&w/dye.
73206.........  Ct angio upr extrm w/ ......  S             0662      4.8552      298.44      118.88       59.69
                 o&w/dye.
73218.........  Mri upper extremity   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
73219.........  Mri upper extremity   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
73220.........  Mri uppr extremity w/ ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
73221.........  Mri joint upr extrem  ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
73222.........  Mri joint upr extrem  ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
73223.........  Mri joint upr extr w/ ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
73500.........  X-ray exam of hip...  ......  X             0260      0.7093       43.60  ..........        8.72
73510.........  X-ray exam of hip...  ......  X             0260      0.7093       43.60  ..........        8.72
73520.........  X-ray exam of hips..  ......  X             0261      1.2224       75.14  ..........       15.03
73525.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 hip.
73530.........  X-ray exam of hip...  ......  X             0261      1.2224       75.14  ..........       15.03
73540.........  X-ray exam of pelvis  ......  X             0260      0.7093       43.60  ..........        8.72
                 & hips.
73542.........  X-ray exam,           ......  S             0275      3.6915      226.91       69.09       45.38
                 sacroiliac joint.
73550.........  X-ray exam of thigh.  ......  X             0260      0.7093       43.60  ..........        8.72
73560.........  X-ray exam of knee,   ......  X             0260      0.7093       43.60  ..........        8.72
                 1 or 2.
73562.........  X-ray exam of knee,   ......  X             0260      0.7093       43.60  ..........        8.72
                 3.
73564.........  X-ray exam, knee, 4   ......  X             0260      0.7093       43.60  ..........        8.72
                 or more.
73565.........  X-ray exam of knees.  ......  X             0260      0.7093       43.60  ..........        8.72
73580.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 knee joint.
73590.........  X-ray exam of lower   ......  X             0260      0.7093       43.60  ..........        8.72
                 leg.
73592.........  X-ray exam of leg,    ......  X             0260      0.7093       43.60  ..........        8.72
                 infant.
73600.........  X-ray exam of ankle.  ......  X             0260      0.7093       43.60  ..........        8.72
73610.........  X-ray exam of ankle.  ......  X             0260      0.7093       43.60  ..........        8.72
73615.........  Contrast x-ray of     ......  S             0275      3.6915      226.91       69.09       45.38
                 ankle.
73620.........  X-ray exam of foot..  ......  X             0260      0.7093       43.60  ..........        8.72
73630.........  X-ray exam of foot..  ......  X             0260      0.7093       43.60  ..........        8.72
73650.........  X-ray exam of heel..  ......  X             0260      0.7093       43.60  ..........        8.72
73660.........  X-ray exam of toe(s)  ......  X             0260      0.7093       43.60  ..........        8.72
73700.........  Ct lower extremity w/ ......  S             0332      3.0908      189.99       75.24       38.00
                 o dye.
73701.........  Ct lower extremity w/ ......  S             0283      4.0825      250.94      100.37       50.19
                 dye.
73702.........  Ct lwr extremity w/   ......  S             0333      4.8405      297.54      119.01       59.51
                 o&w/dye.
73706.........  Ct angio lwr extr w/  ......  S             0662      4.8552      298.44      118.88       59.69
                 o&w/dye.
73718.........  Mri lower extremity   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
73719.........  Mri lower extremity   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
73720.........  Mri lwr extremity w/  ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
73721.........  Mri jnt of lwr extre  ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
73722.........  Mri joint of lwr      ......  S             0284      6.1231      376.37      148.40       75.27
                 extr w/dye.
73723.........  Mri joint lwr extr w/ ......  S             0337      8.1155      498.84      199.53       99.77
                 o&w/dye.
74000.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 abdomen.
74010.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 abdomen.
74020.........  X-ray exam of         ......  X             0260      0.7093       43.60  ..........        8.72
                 abdomen.
74022.........  X-ray exam series,    ......  X             0261      1.2224       75.14  ..........       15.03
                 abdomen.
74150.........  Ct abdomen w/o dye..  ......  S             0332      3.0908      189.99       75.24       38.00
74160.........  Ct abdomen w/dye....  ......  S             0283      4.0825      250.94      100.37       50.19
74170.........  Ct abdomen w/o & w/   ......  S             0333      4.8405      297.54      119.01       59.51
                 dye.
74175.........  Ct angio abdom w/o &  ......  S             0662      4.8552      298.44      118.88       59.69
                 w/dye.
74181.........  Mri abdomen w/o dye.  ......  S             0336      5.6745      348.80      139.51       69.76
74182.........  Mri abdomen w/dye...  ......  S             0284      6.1231      376.37      148.40       75.27
74183.........  Mri abdomen w/o & w/  ......  S             0337      8.1155      498.84      199.53       99.77
                 dye.
74190.........  X-ray exam of         ......  X             0264      2.9586      181.86       70.27       36.37
                 peritoneum.
74210.........  Contrst x-ray exam    ......  S             0276      1.4294       87.86       34.97       17.57
                 of throat.
74220.........  Contrast x-ray,       ......  S             0276      1.4294       87.86       34.97       17.57
                 esophagus.
74230.........  Cine/vid x-ray,       ......  S             0276      1.4294       87.86       34.97       17.57
                 throat/esoph.

[[Page 68345]]

 
74235.........  Remove esophagus       CH...  S             0257      1.0974       67.45  ..........       13.49
                 obstruction.
74240.........  X-ray exam, upper gi  ......  S             0276      1.4294       87.86       34.97       17.57
                 tract.
74241.........  X-ray exam, upper gi  ......  S             0276      1.4294       87.86       34.97       17.57
                 tract.
74245.........  X-ray exam, upper gi  ......  S             0277      2.2176      136.31       54.52       27.26
                 tract.
74246.........  Contrst x-ray uppr    ......  S             0276      1.4294       87.86       34.97       17.57
                 gi tract.
74247.........  Contrst x-ray uppr    ......  S             0276      1.4294       87.86       34.97       17.57
                 gi tract.
74249.........  Contrst x-ray uppr    ......  S             0277      2.2176      136.31       54.52       27.26
                 gi tract.
74250.........  X-ray exam of small   ......  S             0276      1.4294       87.86       34.97       17.57
                 bowel.
74251.........  X-ray exam of small   ......  S             0277      2.2176      136.31       54.52       27.26
                 bowel.
74260.........  X-ray exam of small    CH...  S             0276      1.4294       87.86       34.97       17.57
                 bowel.
74270.........  Contrast x-ray exam   ......  S             0276      1.4294       87.86       34.97       17.57
                 of colon.
74280.........  Contrast x-ray exam   ......  S             0277      2.2176      136.31       54.52       27.26
                 of colon.
74283.........  Contrast x-ray exam   ......  S             0276      1.4294       87.86       34.97       17.57
                 of colon.
74290.........  Contrast x-ray,       ......  S             0276      1.4294       87.86       34.97       17.57
                 gallbladder.
74291.........  Contrast x-rays,      ......  S             0276      1.4294       87.86       34.97       17.57
                 gallbladder.
74300.........  X-ray bile ducts/     ......  X             0263      1.6956      104.23       23.77       20.85
                 pancreas.
74301.........  X-rays at surgery     ......  X             0263      1.6956      104.23       23.77       20.85
                 add-on.
74305.........  X-ray bile ducts/     ......  X             0263      1.6956      104.23       23.77       20.85
                 pancreas.
74320.........  Contrast x-ray of     ......  X             0264      2.9586      181.86       70.27       36.37
                 bile ducts.
74327.........  X-ray bile stone      ......  S             0296      2.6802      164.75       53.99       32.95
                 removal.
74328.........  X-ray bile duct       ......  N       ..........  ..........  ..........  ..........  ..........
                 endoscopy.
74329.........  X-ray for pancreas    ......  N       ..........  ..........  ..........  ..........  ..........
                 endoscopy.
74330.........  X-ray bile/panc       ......  N       ..........  ..........  ..........  ..........  ..........
                 endoscopy.
74340.........  X-ray guide for GI    ......  X             0272      1.2908       79.34       31.64       15.87
                 tube.
74350.........  X-ray guide, stomach  ......  X             0263      1.6956      104.23       23.77       20.85
                 tube.
74355.........  X-ray guide,          ......  X             0263      1.6956      104.23       23.77       20.85
                 intestinal tube.
74360.........  X-ray guide, GI        CH...  S             0257      1.0974       67.45  ..........       13.49
                 dilation.
74363.........  X-ray, bile duct      ......  S             0297      3.6392      223.69       89.47       44.74
                 dilation.
74400.........  Contrst x-ray,        ......  S             0278      2.4159      148.50       59.40       29.70
                 urinary tract.
74410.........  Contrst x-ray,        ......  S             0278      2.4159      148.50       59.40       29.70
                 urinary tract.
74415.........  Contrst x-ray,        ......  S             0278      2.4159      148.50       59.40       29.70
                 urinary tract.
74420.........  Contrst x-ray,        ......  S             0278      2.4159      148.50       59.40       29.70
                 urinary tract.
74425.........  Contrst x-ray,        ......  S             0278      2.4159      148.50       59.40       29.70
                 urinary tract.
74430.........  Contrast x-ray,       ......  S             0278      2.4159      148.50       59.40       29.70
                 bladder.
74440.........  X-ray, male genital   ......  S             0278      2.4159      148.50       59.40       29.70
                 tract.
74445.........  X-ray exam of penis.  ......  S             0278      2.4159      148.50       59.40       29.70
74450.........  X-ray, urethra/       ......  S             0278      2.4159      148.50       59.40       29.70
                 bladder.
74455.........  X-ray, urethra/       ......  S             0278      2.4159      148.50       59.40       29.70
                 bladder.
74470.........  X-ray exam of kidney  ......  X             0263      1.6956      104.23       23.77       20.85
                 lesion.
74475.........  X-ray control, cath   ......  S             0297      3.6392      223.69       89.47       44.74
                 insert.
74480.........  X-ray control, cath   ......  S             0296      2.6802      164.75       53.99       32.95
                 insert.
74485.........  X-ray guide, GU       ......  S             0296      2.6802      164.75       53.99       32.95
                 dilation.
74710.........  X-ray measurement of  ......  X             0261      1.2224       75.14  ..........       15.03
                 pelvis.
74740.........  X-ray, female         ......  X             0264      2.9586      181.86       70.27       36.37
                 genital tract.
74742.........  X-ray, fallopian      ......  X             0264      2.9586      181.86       70.27       36.37
                 tube.
74775.........  X-ray exam of         ......  S             0278      2.4159      148.50       59.40       29.70
                 perineum.
75552.........  Heart mri for morph   ......  S             0336      5.6745      348.80      139.51       69.76
                 w/o dye.
75553.........  Heart mri for morph   ......  S             0284      6.1231      376.37      148.40       75.27
                 w/dye.
75554.........  Cardiac MRI/function  ......  S             0336      5.6745      348.80      139.51       69.76
75555.........  Cardiac MRI/limited   ......  S             0336      5.6745      348.80      139.51       69.76
                 study.
75600.........  Contrast x-ray exam   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 of aorta.
75605.........  Contrast x-ray exam   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 of aorta.
75625.........  Contrast x-ray exam   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 of aorta.
75630.........  X-ray aorta, leg      ......  S             0280     20.8225    1,279.92      353.85      255.98
                 arteries.
75635.........  Ct angio abdominal    ......  S             0662      4.8552      298.44      118.88       59.69
                 arteries.
75650.........  Artery x-rays, head   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 & neck.
75658.........  Artery x-rays, arm..  ......  S             0279      9.5061      584.32      150.03      116.86
75660.........  Artery x-rays, head   ......  S             0668      6.2463      383.95       88.26       76.79
                 & neck.
75662.........  Artery x-rays, head   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 & neck.
75665.........  Artery x-rays, head   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 & neck.
75671.........  Artery x-rays, head   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 & neck.
75676.........  Artery x-rays, neck.  ......  S             0280     20.8225    1,279.92      353.85      255.98
75680.........  Artery x-rays, neck.  ......  S             0280     20.8225    1,279.92      353.85      255.98
75685.........  Artery x-rays, spine  ......  S             0280     20.8225    1,279.92      353.85      255.98
75705.........  Artery x-rays, spine  ......  S             0668      6.2463      383.95       88.26       76.79
75710.........  Artery x-rays, arm/   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 leg.
75716.........  Artery x-rays, arms/  ......  S             0280     20.8225    1,279.92      353.85      255.98
                 legs.
75722.........  Artery x-rays,        ......  S             0280     20.8225    1,279.92      353.85      255.98
                 kidney.
75724.........  Artery x-rays,        ......  S             0280     20.8225    1,279.92      353.85      255.98
                 kidneys.
75726.........  Artery x-rays,        ......  S             0280     20.8225    1,279.92      353.85      255.98
                 abdomen.

[[Page 68346]]

 
75731.........  Artery x-rays,        ......  S             0280     20.8225    1,279.92      353.85      255.98
                 adrenal gland.
75733.........  Artery x-rays,        ......  S             0668      6.2463      383.95       88.26       76.79
                 adrenals.
75736.........  Artery x-rays,        ......  S             0280     20.8225    1,279.92      353.85      255.98
                 pelvis.
75741.........  Artery x-rays, lung.  ......  S             0279      9.5061      584.32      150.03      116.86
75743.........  Artery x-rays, lungs  ......  S             0280     20.8225    1,279.92      353.85      255.98
75746.........  Artery x-rays, lung.  ......  S             0279      9.5061      584.32      150.03      116.86
75756.........  Artery x-rays, chest  ......  S             0279      9.5061      584.32      150.03      116.86
75774.........  Artery x-ray, each    ......  S             0279      9.5061      584.32      150.03      116.86
                 vessel.
75790.........  Visualize A-V shunt.  ......  S             0279      9.5061      584.32      150.03      116.86
75801.........  Lymph vessel x-ray,   ......  X             0264      2.9586      181.86       70.27       36.37
                 arm/leg.
75803.........  Lymph vessel x-       ......  X             0264      2.9586      181.86       70.27       36.37
                 ray,arms/legs.
75805.........  Lymph vessel x-ray,   ......  X             0264      2.9586      181.86       70.27       36.37
                 trunk.
75807.........  Lymph vessel x-ray,   ......  X             0264      2.9586      181.86       70.27       36.37
                 trunk.
75809.........  Nonvascular shunt, x- ......  X             0263      1.6956      104.23       23.77       20.85
                 ray.
75810.........  Vein x-ray, spleen/   ......  S             0279      9.5061      584.32      150.03      116.86
                 liver.
75820.........  Vein x-ray, arm/leg.  ......  S             0668      6.2463      383.95       88.26       76.79
75822.........  Vein x-ray, arms/     ......  S             0668      6.2463      383.95       88.26       76.79
                 legs.
75825.........  Vein x-ray, trunk...  ......  S             0279      9.5061      584.32      150.03      116.86
75827.........  Vein x-ray, chest...  ......  S             0279      9.5061      584.32      150.03      116.86
75831.........  Vein x-ray, kidney..  ......  S             0279      9.5061      584.32      150.03      116.86
75833.........  Vein x-ray, kidneys.  ......  S             0279      9.5061      584.32      150.03      116.86
75840.........  Vein x-ray, adrenal   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 gland.
75842.........  Vein x-ray, adrenal   ......  S             0280     20.8225    1,279.92      353.85      255.98
                 glands.
75860.........  Vein x-ray, neck....  ......  S             0668      6.2463      383.95       88.26       76.79
75870.........  Vein x-ray, skull...  ......  S             0668      6.2463      383.95       88.26       76.79
75872.........  Vein x-ray, skull...  ......  S             0279      9.5061      584.32      150.03      116.86
75880.........  Vein x-ray, eye       ......  S             0668      6.2463      383.95       88.26       76.79
                 socket.
75885.........  Vein x-ray, liver...  ......  S             0280     20.8225    1,279.92      353.85      255.98
75887.........  Vein x-ray, liver...  ......  S             0279      9.5061      584.32      150.03      116.86
75889.........  Vein x-ray, liver...  ......  S             0280     20.8225    1,279.92      353.85      255.98
75891.........  Vein x-ray, liver...  ......  S             0279      9.5061      584.32      150.03      116.86
75893.........  Venous sampling by     CH...  Q             0668      6.2463      383.95       88.26       76.79
                 catheter.
75894.........  X-rays, transcath      CH...  S             0298      8.3906      515.75      206.30      103.15
                 therapy.
75896.........  X-rays, transcath      CH...  S             0298      8.3906      515.75      206.30      103.15
                 therapy.
75898.........  Follow-up             ......  X             0263      1.6956      104.23       23.77       20.85
                 angiography.
75901.........  Remove cva device     ......  X             0263      1.6956      104.23       23.77       20.85
                 obstruct.
75902.........  Remove cva lumen      ......  X             0263      1.6956      104.23       23.77       20.85
                 obstruct.
75940.........  X-ray placement,       CH...  S             0298      8.3906      515.75      206.30      103.15
                 vein filter.
75945.........  Intravascular us....  ......  S             0267      2.4606      151.25       60.50       30.25
75946.........  Intravascular us add- ......  S             0266      1.5607       95.93       37.80       19.19
                 on.
75960.........  Transcath iv stent    ......  S             0668      6.2463      383.95       88.26       76.79
                 rs&i.
75961.........  Retrieval, broken     ......  S             0668      6.2463      383.95       88.26       76.79
                 catheter.
75962.........  Repair arterial       ......  S             0668      6.2463      383.95       88.26       76.79
                 blockage.
75964.........  Repair artery         ......  S             0668      6.2463      383.95       88.26       76.79
                 blockage, each.
75966.........  Repair arterial       ......  S             0668      6.2463      383.95       88.26       76.79
                 blockage.
75968.........  Repair artery         ......  S             0668      6.2463      383.95       88.26       76.79
                 blockage, each.
75970.........  Vascular biopsy.....  ......  S             0668      6.2463      383.95       88.26       76.79
75978.........  Repair venous         ......  S             0668      6.2463      383.95       88.26       76.79
                 blockage.
75980.........  Contrast xray exam    ......  S             0297      3.6392      223.69       89.47       44.74
                 bile duct.
75982.........  Contrast xray exam    ......  S             0297      3.6392      223.69       89.47       44.74
                 bile duct.
75984.........  Xray control          ......  X             0263      1.6956      104.23       23.77       20.85
                 catheter change.
75989.........  Abscess drainage      ......  N       ..........  ..........  ..........  ..........  ..........
                 under x-ray.
75992.........  Atherectomy, x-ray     CH...  S             0668      6.2463      383.95       88.26       76.79
                 exam.
75993.........  Atherectomy, x-ray     CH...  S             0668      6.2463      383.95       88.26       76.79
                 exam.
75994.........  Atherectomy, x-ray     CH...  S             0668      6.2463      383.95       88.26       76.79
                 exam.
75995.........  Atherectomy, x-ray     CH...  S             0668      6.2463      383.95       88.26       76.79
                 exam.
75996.........  Atherectomy, x-ray     CH...  S             0668      6.2463      383.95       88.26       76.79
                 exam.
75998.........  Fluoroguide for vein   CH...  D       ..........  ..........  ..........  ..........  ..........
                 device.
76000.........  Fluoroscope           ......  X             0272      1.2908       79.34       31.64       15.87
                 examination.
76001.........  Fluoroscope exam,     ......  N       ..........  ..........  ..........  ..........  ..........
                 extensive.
76003.........  Needle localization    CH...  D       ..........  ..........  ..........  ..........  ..........
                 by x-ray.
76005.........  Fluoroguide for        CH...  D       ..........  ..........  ..........  ..........  ..........
                 spine inject.
76006.........  X-ray stress view...   CH...  D       ..........  ..........  ..........  ..........  ..........
76010.........  X-ray, nose to        ......  X             0260      0.7093       43.60  ..........        8.72
                 rectum.
76012.........  Percut                 CH...  D       ..........  ..........  ..........  ..........  ..........
                 vertebroplasty
                 fluor.
76013.........  Percut                 CH...  D       ..........  ..........  ..........  ..........  ..........
                 vertebroplasty, ct.
76020.........  X-rays for bone age.   CH...  D       ..........  ..........  ..........  ..........  ..........
76040.........  X-rays, bone           CH...  D       ..........  ..........  ..........  ..........  ..........
                 evaluation.
76061.........  X-rays, bone survey.   CH...  D       ..........  ..........  ..........  ..........  ..........
76062.........  X-rays, bone survey.   CH...  D       ..........  ..........  ..........  ..........  ..........

[[Page 68347]]

 
76065.........  X-rays, bone           CH...  D       ..........  ..........  ..........  ..........  ..........
                 evaluation.
76066.........  Joint survey, single   CH...  D       ..........  ..........  ..........  ..........  ..........
                 view.
76070.........  Ct bone density,       CH...  D       ..........  ..........  ..........  ..........  ..........
                 axial.
76071.........  Ct bone density,       CH...  D       ..........  ..........  ..........  ..........  ..........
                 peripheral.
76075.........  Dxa bone density,      CH...  D       ..........  ..........  ..........  ..........  ..........
                 axial.
76076.........  Dxa bone density/      CH...  D       ..........  ..........  ..........  ..........  ..........
                 peripheral.
76077.........  Dxa bone density/v-    CH...  D       ..........  ..........  ..........  ..........  ..........
                 fracture.
76078.........  Radiographic           CH...  D       ..........  ..........  ..........  ..........  ..........
                 absorptiometry.
76080.........  X-ray exam of         ......  X             0263      1.6956      104.23       23.77       20.85
                 fistula.
76082.........  Computer mammogram     CH...  D       ..........  ..........  ..........  ..........  ..........
                 add-on.
76083.........  Computer mammogram     CH...  D       ..........  ..........  ..........  ..........  ..........
                 add-on.
76086.........  X-ray of mammary       CH...  D       ..........  ..........  ..........  ..........  ..........
                 duct.
76088.........  X-ray of mammary       CH...  D       ..........  ..........  ..........  ..........  ..........
                 ducts.
76090.........  Mammogram, one         CH...  D       ..........  ..........  ..........  ..........  ..........
                 breast.
76091.........  Mammogram, both        CH...  D       ..........  ..........  ..........  ..........  ..........
                 breasts.
76092.........  Mammogram, screening   CH...  D       ..........  ..........  ..........  ..........  ..........
76093.........  Magnetic image,        CH...  D       ..........  ..........  ..........  ..........  ..........
                 breast.
76094.........  Magnetic image, both   CH...  D       ..........  ..........  ..........  ..........  ..........
                 breasts.
76095.........  Stereotactic breast    CH...  D       ..........  ..........  ..........  ..........  ..........
                 biopsy.
76096.........  X-ray of needle        CH...  D       ..........  ..........  ..........  ..........  ..........
                 wire, breast.
76098.........  X-ray exam, breast    ......  X             0260      0.7093       43.60  ..........        8.72
                 specimen.
76100.........  X-ray exam of body    ......  X             0261      1.2224       75.14  ..........       15.03
                 section.
76101.........  Complex body section  ......  X             0263      1.6956      104.23       23.77       20.85
                 x-ray.
76102.........  Complex body section  ......  X             0264      2.9586      181.86       70.27       36.37
                 x-rays.
76120.........  Cine/video x-rays...  ......  X             0272      1.2908       79.34       31.64       15.87
76125.........  Cine/video x-rays     ......  X             0260      0.7093       43.60  ..........        8.72
                 add-on.
76150.........  X-ray exam, dry       ......  X             0260      0.7093       43.60  ..........        8.72
                 process.
76350.........  Special x-ray         ......  N       ..........  ..........  ..........  ..........  ..........
                 contrast study.
76355.........  Ct scan for            CH...  D       ..........  ..........  ..........  ..........  ..........
                 localization.
76360.........  Ct scan for needle     CH...  D       ..........  ..........  ..........  ..........  ..........
                 biopsy.
76362.........  Ct guide for tissue    CH...  D       ..........  ..........  ..........  ..........  ..........
                 ablation.
76370.........  Ct scan for therapy    CH...  D       ..........  ..........  ..........  ..........  ..........
                 guide.
76376.........  3d render w/o         ......  X             0340      0.6102       37.51  ..........        7.50
                 postprocess.
76377.........  3d rendering w/       ......  S             0282      1.5379       94.53       37.81       18.91
                 postprocess.
76380.........  CAT scan follow-up    ......  S             0282      1.5379       94.53       37.81       18.91
                 study.
76393.........  Mr guidance for        CH...  D       ..........  ..........  ..........  ..........  ..........
                 needle place.
76394.........  Mri for tissue         CH...  D       ..........  ..........  ..........  ..........  ..........
                 ablation.
76400.........  Magnetic image, bone   CH...  D       ..........  ..........  ..........  ..........  ..........
                 marrow.
76496.........  Fluoroscopic          ......  X             0272      1.2908       79.34       31.64       15.87
                 procedure.
76497.........  Ct procedure........  ......  S             0282      1.5379       94.53       37.81       18.91
76498.........  Mri procedure.......  ......  S             0335      4.5523      279.82      111.92       55.96
76499.........  Radiographic          ......  X             0260      0.7093       43.60  ..........        8.72
                 procedure.
76506.........  Echo exam of head...  ......  S             0265      0.9923       60.99       23.63       12.20
76510.........  Ophth us, b & quant   ......  S             0266      1.5607       95.93       37.80       19.19
                 a.
76511.........  Ophth us, quant a     ......  S             0266      1.5607       95.93       37.80       19.19
                 only.
76512.........  Ophth us, b w/non-    ......  S             0266      1.5607       95.93       37.80       19.19
                 quant a.
76513.........  Echo exam of eye,     ......  S             0266      1.5607       95.93       37.80       19.19
                 water bath.
76514.........  Echo exam of eye,     ......  X             0340      0.6102       37.51  ..........        7.50
                 thickness.
76516.........  Echo exam of eye....  ......  S             0265      0.9923       60.99       23.63       12.20
76519.........  Echo exam of eye....  ......  S             0266      1.5607       95.93       37.80       19.19
76529.........  Echo exam of eye....  ......  S             0265      0.9923       60.99       23.63       12.20
76536.........  Us exam of head and   ......  S             0266      1.5607       95.93       37.80       19.19
                 neck.
76604.........  Us exam, chest......   CH...  S             0265      0.9923       60.99       23.63       12.20
76645.........  Us exam, breast(s)..  ......  S             0265      0.9923       60.99       23.63       12.20
76700.........  Us exam, abdom,       ......  S             0266      1.5607       95.93       37.80       19.19
                 complete.
76705.........  Echo exam of abdomen  ......  S             0266      1.5607       95.93       37.80       19.19
76770.........  Us exam abdo back     ......  S             0266      1.5607       95.93       37.80       19.19
                 wall, comp.
76775.........  Us exam abdo back     ......  S             0266      1.5607       95.93       37.80       19.19
                 wall, lim.
76776.........  Us exam k transpl w/   NI...  S             0266      1.5607       95.93       37.80       19.19
                 doppler.
76778.........  Us exam kidney         CH...  D       ..........  ..........  ..........  ..........  ..........
                 transplant.
76800.........  Us exam, spinal       ......  S             0266      1.5607       95.93       37.80       19.19
                 canal.
76801.........  Ob us < 14 wks,       ......  S             0266      1.5607       95.93       37.80       19.19
                 single fetus.
76802.........  Ob us < 14 wks,       ......  S             0265      0.9923       60.99       23.63       12.20
                 add[AElig]l fetus.
76805.........  Ob us [gE] 14 wks,    ......  S             0266      1.5607       95.93       37.80       19.19
                 sngl fetus.
76810.........  Ob us [gE] 14 wks,    ......  S             0266      1.5607       95.93       37.80       19.19
                 addl fetus.
76811.........  Ob us, detailed,      ......  S             0267      2.4606      151.25       60.50       30.25
                 sngl fetus.
76812.........  Ob us, detailed,       CH...  S             0265      0.9923       60.99       23.63       12.20
                 addl fetus.
76813.........  Ob us nuchal meas, 1   NI...  S             0266      1.5607       95.93       37.80       19.19
                 gest.
76814.........  Ob us nuchal meas,     NI...  S             0265      0.9923       60.99       23.63       12.20
                 add-on.
76815.........  Ob us, limited,       ......  S             0265      0.9923       60.99       23.63       12.20
                 fetus(s).

[[Page 68348]]

 
76816.........  Ob us, follow-up,     ......  S             0265      0.9923       60.99       23.63       12.20
                 per fetus.
76817.........  Transvaginal us,       CH...  S             0265      0.9923       60.99       23.63       12.20
                 obstetric.
76818.........  Fetal biophys         ......  S             0266      1.5607       95.93       37.80       19.19
                 profile w/nst.
76819.........  Fetal biophys profil  ......  S             0266      1.5607       95.93       37.80       19.19
                 w/o nst.
76820.........  Umbilical artery      ......  S             0096      1.5303       94.06       37.62       18.81
                 echo.
76821.........  Middle cerebral       ......  S             0096      1.5303       94.06       37.62       18.81
                 artery echo.
76825.........  Echo exam of fetal     CH...  S             0697      1.5973       98.18       35.99       19.64
                 heart.
76826.........  Echo exam of fetal    ......  S             0697      1.5973       98.18       35.99       19.64
                 heart.
76827.........  Echo exam of fetal     CH...  S             0697      1.5973       98.18       35.99       19.64
                 heart.
76828.........  Echo exam of fetal    ......  S             0697      1.5973       98.18       35.99       19.64
                 heart.
76830.........  Transvaginal us, non- ......  S             0266      1.5607       95.93       37.80       19.19
                 ob.
76831.........  Echo exam, uterus...  ......  S             0267      2.4606      151.25       60.50       30.25
76856.........  Us exam, pelvic,      ......  S             0266      1.5607       95.93       37.80       19.19
                 complete.
76857.........  Us exam, pelvic,      ......  S             0265      0.9923       60.99       23.63       12.20
                 limited.
76870.........  Us exam, scrotum....  ......  S             0266      1.5607       95.93       37.80       19.19
76872.........  Us, transrectal.....  ......  S             0266      1.5607       95.93       37.80       19.19
76873.........  Echograp trans r,     ......  S             0266      1.5607       95.93       37.80       19.19
                 pros study.
76880.........  Us exam, extremity..  ......  S             0266      1.5607       95.93       37.80       19.19
76885.........  Us exam infant hips,  ......  S             0265      0.9923       60.99       23.63       12.20
                 dynamic.
76886.........  Us exam infant hips,   CH...  S             0265      0.9923       60.99       23.63       12.20
                 static.
76930.........  Echo guide,           ......  S             0268      1.1882       73.04  ..........       14.61
                 cardiocentesis.
76932.........  Echo guide for heart   CH...  S             0309      2.1012      129.16  ..........       25.83
                 biopsy.
76936.........  Echo guide for         CH...  S             0309      2.1012      129.16  ..........       25.83
                 artery repair.
76937.........  Us guide, vascular    ......  N       ..........  ..........  ..........  ..........  ..........
                 access.
76940.........  Us guide, tissue      ......  S             0268      1.1882       73.04  ..........       14.61
                 ablation.
76941.........  Echo guide for        ......  S             0268      1.1882       73.04  ..........       14.61
                 transfusion.
76942.........  Echo guide for        ......  S             0268      1.1882       73.04  ..........       14.61
                 biopsy.
76945.........  Echo guide, villus    ......  S             0268      1.1882       73.04  ..........       14.61
                 sampling.
76946.........  Echo guide for        ......  S             0268      1.1882       73.04  ..........       14.61
                 amniocentesis.
76948.........  Echo guide, ova        CH...  S             0309      2.1012      129.16  ..........       25.83
                 aspiration.
76950.........  Echo guidance         ......  S             0268      1.1882       73.04  ..........       14.61
                 radiotherapy.
76965.........  Echo guidance          CH...  S             0309      2.1012      129.16  ..........       25.83
                 radiotherapy.
76970.........  Ultrasound exam       ......  S             0265      0.9923       60.99       23.63       12.20
                 follow-up.
76975.........  GI endoscopic         ......  S             0266      1.5607       95.93       37.80       19.19
                 ultrasound.
76977.........  Us bone density       ......  X             0340      0.6102       37.51  ..........        7.50
                 measure.
76986.........  Ultrasound guide       CH...  D       ..........  ..........  ..........  ..........  ..........
                 intraoper.
76998.........  Us guide, intraop...   NI...  S             0266      1.5607       95.93       37.80       19.19
76999.........  Echo examination      ......  S             0265      0.9923       60.99       23.63       12.20
                 procedure.
77001.........  Fluoroguide for vein   NI...  N       ..........  ..........  ..........  ..........  ..........
                 device.
77002.........  Needle localization    NI...  N       ..........  ..........  ..........  ..........  ..........
                 by xray.
77003.........  Fluoroguide for        NI...  N       ..........  ..........  ..........  ..........  ..........
                 spine inject.
77011.........  Ct scan for            NI...  S             0283      4.0825      250.94      100.37       50.19
                 localization.
77012.........  Ct scan for needle     NI...  S             0283      4.0825      250.94      100.37       50.19
                 biopsy.
77013.........  Ct guide for tissue    NI...  S             0333      4.8405      297.54      119.01       59.51
                 ablation.
77014.........  Ct scan for therapy    NI...  S             0282      1.5379       94.53       37.81       18.91
                 guide.
77021.........  Mr guidance for        NI...  S             0335      4.5523      279.82      111.92       55.96
                 needle place.
77022.........  Mri for tissue         NI...  S             0335      4.5523      279.82      111.92       55.96
                 ablation.
77031.........  Stereotact guide for   NI...  X             0264      2.9586      181.86       70.27       36.37
                 brst bx.
77032.........  Guidance for needle,   NI...  X             0263      1.6956      104.23       23.77       20.85
                 breast.
77051.........  Computer dx            NI...  A       ..........  ..........  ..........  ..........  ..........
                 mammogram add-on.
77052.........  Comp screen            NI...  A       ..........  ..........  ..........  ..........  ..........
                 mammogram add-on.
77053.........  X-ray of mammary       NI...  X             0263      1.6956      104.23       23.77       20.85
                 duct.
77054.........  X-ray of mammary       NI...  X             0263      1.6956      104.23       23.77       20.85
                 ducts.
77055.........  Mammogram, one         NI...  A       ..........  ..........  ..........  ..........  ..........
                 breast.
77056.........  Mammogram, both        NI...  A       ..........  ..........  ..........  ..........  ..........
                 breasts.
77057.........  Mammogram, screening   NI...  A       ..........  ..........  ..........  ..........  ..........
77058.........  Mri, one breast.....   NI...  B       ..........  ..........  ..........  ..........  ..........
77059.........  Mri, both breasts...   NI...  B       ..........  ..........  ..........  ..........  ..........
77071.........  X-ray stress view...   NI...  X             0260      0.7093       43.60  ..........        8.72
77072.........  X-rays for bone age.   NI...  X             0260      0.7093       43.60  ..........        8.72
77073.........  X-rays, bone length    NI...  X             0260      0.7093       43.60  ..........        8.72
                 studies.
77074.........  X-rays, bone survey,   NI...  X             0261      1.2224       75.14  ..........       15.03
                 limited.
77075.........  X-rays, bone survey    NI...  X             0261      1.2224       75.14  ..........       15.03
                 complete.
77076.........  X-rays, bone survey,   NI...  X             0260      0.7093       43.60  ..........        8.72
                 infant.
77077.........  Joint survey, single   NI...  X             0260      0.7093       43.60  ..........        8.72
                 view.
77078.........  Ct bone density,       NI...  S             0288      1.1755       72.26       28.90       14.45
                 axial.
77079.........  Ct bone density,       NI...  S             0282      1.5379       94.53       37.81       18.91
                 peripheral.
77080.........  Dxa bone density,      NI...  S             0288      1.1755       72.26       28.90       14.45
                 axial.
77081.........  Dxa bone density/      NI...  S             0665      0.5497       33.79       13.51        6.76
                 peripheral.
77082.........  Dxa bone density,      NI...  X             0260      0.7093       43.60  ..........        8.72
                 vert fx.

[[Page 68349]]

 
77083.........  Radiographic           NI...  X             0261      1.2224       75.14  ..........       15.03
                 absorptiometry.
77084.........  Magnetic image, bone   NI...  S             0335      4.5523      279.82      111.92       55.96
                 marrow.
77280.........  Sbrt management.....  ......  X             0304      1.5735       96.72       38.68       19.34
77285.........  Set radiation         ......  X             0305      3.9723      244.17       91.38       48.83
                 therapy field.
77290.........  Set radiation         ......  X             0305      3.9723      244.17       91.38       48.83
                 therapy field.
77295.........  Set radiation         ......  X             0310     13.8081      848.76      325.27      169.75
                 therapy field.
77299.........  Radiation therapy     ......  X             0304      1.5735       96.72       38.68       19.34
                 planning.
77300.........  Radiation therapy     ......  X             0304      1.5735       96.72       38.68       19.34
                 dose plan.
77301.........  Radiotherapy dose     ......  X             0310     13.8081      848.76      325.27      169.75
                 plan, imrt.
77305.........  Teletx isodose plan   ......  X             0304      1.5735       96.72       38.68       19.34
                 simple.
77310.........  Teletx isodose plan   ......  X             0305      3.9723      244.17       91.38       48.83
                 intermed.
77315.........  Teletx isodose plan   ......  X             0305      3.9723      244.17       91.38       48.83
                 complex.
77321.........  Special teletx port   ......  X             0305      3.9723      244.17       91.38       48.83
                 plan.
77326.........  Brachytx isodose      ......  X             0304      1.5735       96.72       38.68       19.34
                 calc simp.
77327.........  Brachytx isodose      ......  X             0305      3.9723      244.17       91.38       48.83
                 calc interm.
77328.........  Brachytx isodose      ......  X             0305      3.9723      244.17       91.38       48.83
                 plan compl.
77331.........  Special radiation     ......  X             0304      1.5735       96.72       38.68       19.34
                 dosimetry.
77332.........  Radiation treatment   ......  X             0303       2.943      180.90       66.95       36.18
                 aid(s).
77333.........  Radiation treatment   ......  X             0303       2.943      180.90       66.95       36.18
                 aid(s).
77334.........  Radiation treatment   ......  X             0303       2.943      180.90       66.95       36.18
                 aid(s).
77336.........  Radiation physics     ......  X             0304      1.5735       96.72       38.68       19.34
                 consult.
77370.........  Radiation physics     ......  X             0304      1.5735       96.72       38.68       19.34
                 consult.
77371.........  Srs, multisource....   NI...  S             0127    138.4486    8,510.16  ..........    1,702.03
77372.........  Srs, linear based...   NI...  B       ..........  ..........  ..........  ..........  ..........
77373.........  Sbrt delivery.......   NI...  B       ..........  ..........  ..........  ..........  ..........
77399.........  External radiation    ......  X             0304      1.5735       96.72       38.68       19.34
                 dosimetry.
77401.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77402.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77403.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77404.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77406.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77407.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77408.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77409.........  Radiation treatment   ......  S             0300      1.4826       91.13  ..........       18.23
                 delivery.
77411.........  Radiation treatment   ......  S             0301      2.2295      137.04  ..........       27.41
                 delivery.
77412.........  Radiation treatment   ......  S             0301      2.2295      137.04  ..........       27.41
                 delivery.
77413.........  Radiation treatment   ......  S             0301      2.2295      137.04  ..........       27.41
                 delivery.
77414.........  Radiation treatment   ......  S             0301      2.2295      137.04  ..........       27.41
                 delivery.
77416.........  Radiation treatment   ......  S             0301      2.2295      137.04  ..........       27.41
                 delivery.
77417.........  Radiology port        ......  X             0260      0.7093       43.60  ..........        8.72
                 film(s).
77418.........  Radiation tx          ......  S             0412      5.4731      336.42  ..........       67.28
                 delivery, imrt.
77421.........  Stereoscopic x-ray     CH...  S             0257      1.0974       67.45  ..........       13.49
                 guidance.
77422.........  Neutron beam tx,      ......  S             0301      2.2295      137.04  ..........       27.41
                 simple.
77423.........  Neutron beam tx,      ......  S             0301      2.2295      137.04  ..........       27.41
                 complex.
77435.........  Sbrt management.....   NI...  N       ..........  ..........  ..........  ..........  ..........
77470.........  Special radiation     ......  S             0299      5.8839      361.67  ..........       72.33
                 treatment.
77520.........  Proton trmt, simple   ......  S             0664     18.8926    1,161.29  ..........      232.26
                 w/o comp.
77522.........  Proton trmt, simple   ......  S             0664     18.8926    1,161.29  ..........      232.26
                 w/comp.
77523.........  Proton trmt,          ......  S             0667     22.6031    1,389.37  ..........      277.87
                 intermediate.
77525.........  Proton treatment,     ......  S             0667     22.6031    1,389.37  ..........      277.87
                 complex.
77600.........  Hyperthermia          ......  S             0314      3.3461      205.68       60.88       41.14
                 treatment.
77605.........  Hyperthermia          ......  S             0314      3.3461      205.68       60.88       41.14
                 treatment.
77610.........  Hyperthermia          ......  S             0314      3.3461      205.68       60.88       41.14
                 treatment.
77615.........  Hyperthermia          ......  S             0314      3.3461      205.68       60.88       41.14
                 treatment.
77620.........  Hyperthermia          ......  S             0314      3.3461      205.68       60.88       41.14
                 treatment.
77750.........  Infuse radioactive    ......  S             0301      2.2295      137.04  ..........       27.41
                 materials.
77761.........  Apply intrcav radiat  ......  S             0312      4.8569      298.54  ..........       59.71
                 simple.
77762.........  Apply intrcav radiat  ......  S             0312      4.8569      298.54  ..........       59.71
                 interm.
77763.........  Apply intrcav radiat  ......  S             0312      4.8569      298.54  ..........       59.71
                 compl.
77776.........  Apply interstit       ......  S             0312      4.8569      298.54  ..........       59.71
                 radiat simpl.
77777.........  Apply interstit       ......  S             0312      4.8569      298.54  ..........       59.71
                 radiat inter.
77778.........  Apply interstit       ......  S             0651     16.8462    1,035.50  ..........      207.10
                 radiat compl.
77781.........  High intensity        ......  S             0313     12.8473      789.70  ..........      157.94
                 brachytherapy.
77782.........  High intensity        ......  S             0313     12.8473      789.70  ..........      157.94
                 brachytherapy.
77783.........  High intensity        ......  S             0313     12.8473      789.70  ..........      157.94
                 brachytherapy.
77784.........  High intensity        ......  S             0313     12.8473      789.70  ..........      157.94
                 brachytherapy.
77789.........  Apply surface         ......  S             0300      1.4826       91.13  ..........       18.23
                 radiation.
77790.........  Radiation handling..  ......  N       ..........  ..........  ..........  ..........  ..........
77799.........  Radium/radioisotope    CH...  S             0312      4.8569      298.54  ..........       59.71
                 therapy.
78000.........  Thyroid, single       ......  S             0389      1.3754       84.54       33.81       16.91
                 uptake.

[[Page 68350]]

 
78001.........  Thyroid, multiple     ......  S             0389      1.3754       84.54       33.81       16.91
                 uptakes.
78003.........  Thyroid suppress/     ......  S             0392      2.0057      123.29       49.31       24.66
                 stimul.
78006.........  Thyroid imaging with  ......  S             0390      2.3432      144.03       57.61       28.81
                 uptake.
78007.........  Thyroid image, mult   ......  S             0391      2.7146      166.86       66.18       33.37
                 uptakes.
78010.........  Thyroid imaging.....  ......  S             0390      2.3432      144.03       57.61       28.81
78011.........  Thyroid imaging with  ......  S             0390      2.3432      144.03       57.61       28.81
                 flow.
78015.........  Thyroid met imaging.  ......  S             0406      3.9934      245.47       98.18       49.09
78016.........  Thyroid met imaging/  ......  S             0406      3.9934      245.47       98.18       49.09
                 studies.
78018.........  Thyroid met imaging,  ......  S             0406      3.9934      245.47       98.18       49.09
                 body.
78020.........  Thyroid met uptake..  ......  S             0399      1.5054       92.53       35.80       18.51
78070.........  Parathyroid nuclear   ......  S             0391      2.7146      166.86       66.18       33.37
                 imaging.
78075.........  Adrenal nuclear       ......  S             0391      2.7146      166.86       66.18       33.37
                 imaging.
78099.........  Endocrine nuclear     ......  S             0390      2.3432      144.03       57.61       28.81
                 procedure.
78102.........  Bone marrow imaging,  ......  S             0400      3.9073      240.17       93.22       48.03
                 ltd.
78103.........  Bone marrow imaging,  ......  S             0400      3.9073      240.17       93.22       48.03
                 mult.
78104.........  Bone marrow imaging,  ......  S             0400      3.9073      240.17       93.22       48.03
                 body.
78110.........  Plasma volume,        ......  S             0393      3.7562      230.89       82.04       46.18
                 single.
78111.........  Plasma volume,        ......  S             0393      3.7562      230.89       82.04       46.18
                 multiple.
78120.........  Red cell mass,        ......  S             0393      3.7562      230.89       82.04       46.18
                 single.
78121.........  Red cell mass,        ......  S             0393      3.7562      230.89       82.04       46.18
                 multiple.
78122.........  Blood volume........  ......  S             0393      3.7562      230.89       82.04       46.18
78130.........  Red cell survival     ......  S             0393      3.7562      230.89       82.04       46.18
                 study.
78135.........  Red cell survival     ......  S             0393      3.7562      230.89       82.04       46.18
                 kinetics.
78140.........  Red cell              ......  S             0393      3.7562      230.89       82.04       46.18
                 sequestration.
78185.........  Spleen imaging......  ......  S             0400      3.9073      240.17       93.22       48.03
78190.........  Platelet survival,    ......  S             0392      2.0057      123.29       49.31       24.66
                 kinetics.
78191.........  Platelet survival...  ......  S             0392      2.0057      123.29       49.31       24.66
78195.........  Lymph system imaging  ......  S             0400      3.9073      240.17       93.22       48.03
78199.........  Blood/lymph nuclear   ......  S             0400      3.9073      240.17       93.22       48.03
                 exam.
78201.........  Liver imaging.......  ......  S             0394      4.3774      269.07      102.61       53.81
78202.........  Liver imaging with    ......  S             0394      4.3774      269.07      102.61       53.81
                 flow.
78205.........  Liver imaging (3D)..  ......  S             0394      4.3774      269.07      102.61       53.81
78206.........  Liver image (3d)      ......  S             0394      4.3774      269.07      102.61       53.81
                 with flow.
78215.........  Liver and spleen      ......  S             0394      4.3774      269.07      102.61       53.81
                 imaging.
78216.........  Liver & spleen image/ ......  S             0394      4.3774      269.07      102.61       53.81
                 flow.
78220.........  Liver function study  ......  S             0394      4.3774      269.07      102.61       53.81
78223.........  Hepatobiliary         ......  S             0394      4.3774      269.07      102.61       53.81
                 imaging.
78230.........  Salivary gland        ......  S             0395      3.6526      224.52       89.73       44.90
                 imaging.
78231.........  Serial salivary       ......  S             0395      3.6526      224.52       89.73       44.90
                 imaging.
78232.........  Salivary gland        ......  S             0395      3.6526      224.52       89.73       44.90
                 function exam.
78258.........  Esophageal motility   ......  S             0395      3.6526      224.52       89.73       44.90
                 study.
78261.........  Gastric mucosa        ......  S             0395      3.6526      224.52       89.73       44.90
                 imaging.
78262.........  Gastroesophageal      ......  S             0395      3.6526      224.52       89.73       44.90
                 reflux exam.
78264.........  Gastric emptying      ......  S             0395      3.6526      224.52       89.73       44.90
                 study.
78270.........  Vit B-12 absorption   ......  S             0392      2.0057      123.29       49.31       24.66
                 exam.
78271.........  Vit b-12 absrp exam,  ......  S             0392      2.0057      123.29       49.31       24.66
                 int fac.
78272.........  Vit B-12 absorp,      ......  S             0392      2.0057      123.29       49.31       24.66
                 combined.
78278.........  Acute GI blood loss   ......  S             0395      3.6526      224.52       89.73       44.90
                 imaging.
78282.........  GI protein loss exam  ......  S             0395      3.6526      224.52       89.73       44.90
78290.........  Meckel[AElig]s        ......  S             0395      3.6526      224.52       89.73       44.90
                 divert exam.
78291.........  Leveen/shunt patency  ......  S             0395      3.6526      224.52       89.73       44.90
                 exam.
78299.........  GI nuclear procedure  ......  S             0395      3.6526      224.52       89.73       44.90
78300.........  Bone imaging,         ......  S             0396      3.9174      240.79       95.02       48.16
                 limited area.
78305.........  Bone imaging,         ......  S             0396      3.9174      240.79       95.02       48.16
                 multiple areas.
78306.........  Bone imaging, whole   ......  S             0396      3.9174      240.79       95.02       48.16
                 body.
78315.........  Bone imaging, 3       ......  S             0396      3.9174      240.79       95.02       48.16
                 phase.
78320.........  Bone imaging (3D)...  ......  S             0396      3.9174      240.79       95.02       48.16
78350.........  Bone mineral, single  ......  X             0260      0.7093       43.60  ..........        8.72
                 photon.
78399.........  Musculoskeletal       ......  S             0396      3.9174      240.79       95.02       48.16
                 nuclear exam.
78414.........  Non-imaging heart     ......  S             0398      4.1265      253.65      100.06       50.73
                 function.
78428.........  Cardiac shunt         ......  S             0398      4.1265      253.65      100.06       50.73
                 imaging.
78445.........  Vascular flow         ......  S             0397      2.4204      148.78       49.58       29.76
                 imaging.
78456.........  Acute venous          ......  S             0397      2.4204      148.78       49.58       29.76
                 thrombus image.
78457.........  Venous thrombosis     ......  S             0397      2.4204      148.78       49.58       29.76
                 imaging.
78458.........  Ven thrombosis        ......  S             0397      2.4204      148.78       49.58       29.76
                 images, bilat.
78459.........  Heart muscle imaging   CH...  S             0307     11.8963      731.24      292.49      146.25
                 (PET).
78460.........  Heart muscle blood,   ......  S             0398      4.1265      253.65      100.06       50.73
                 single.
78461.........  Heart muscle blood,   ......  S             0377      6.5012      399.62      158.84       79.92
                 multiple.
78464.........  Heart image (3d),     ......  S             0398      4.1265      253.65      100.06       50.73
                 single.
78465.........  Heart image (3d),     ......  S             0377      6.5012      399.62      158.84       79.92
                 multiple.

[[Page 68351]]

 
78466.........  Heart infarct image.  ......  S             0398      4.1265      253.65      100.06       50.73
78468.........  Heart infarct image   ......  S             0398      4.1265      253.65      100.06       50.73
                 (ef).
78469.........  Heart infarct image   ......  S             0398      4.1265      253.65      100.06       50.73
                 (3D).
78472.........  Gated heart, planar,  ......  S             0398      4.1265      253.65      100.06       50.73
                 single.
78473.........  Gated heart,          ......  S             0376      4.9832      306.31      119.77       61.26
                 multiple.
78478.........  Heart wall motion     ......  S             0399      1.5054       92.53       35.80       18.51
                 add-on.
78480.........  Heart function add-   ......  S             0399      1.5054       92.53       35.80       18.51
                 on.
78481.........  Heart first pass,     ......  S             0398      4.1265      253.65      100.06       50.73
                 single.
78483.........  Heart first pass,     ......  S             0376      4.9832      306.31      119.77       61.26
                 multiple.
78491.........  Heart image (pet),     CH...  S             0307     11.8963      731.24      292.49      146.25
                 single.
78492.........  Heart image (pet),    ......  S             0307     11.8963      731.24      292.49      146.25
                 multiple.
78494.........  Heart image, spect..  ......  S             0398      4.1265      253.65      100.06       50.73
78496.........  Heart first pass add- ......  S             0399      1.5054       92.53       35.80       18.51
                 on.
78499.........  Cardiovascular        ......  S             0398      4.1265      253.65      100.06       50.73
                 nuclear exam.
78580.........  Lung perfusion        ......  S             0401      3.1802      195.48       78.19       39.10
                 imaging.
78584.........  Lung V/Q image        ......  S             0378      5.0975      313.33      125.33       62.67
                 single breath.
78585.........  Lung V/Q imaging....  ......  S             0378      5.0975      313.33      125.33       62.67
78586.........  Aerosol lung image,   ......  S             0401      3.1802      195.48       78.19       39.10
                 single.
78587.........  Aerosol lung image,   ......  S             0401      3.1802      195.48       78.19       39.10
                 multiple.
78588.........  Perfusion lung image  ......  S             0378      5.0975      313.33      125.33       62.67
78591.........  Vent image, 1         ......  S             0401      3.1802      195.48       78.19       39.10
                 breath, 1 proj.
78593.........  Vent image, 1 proj,   ......  S             0401      3.1802      195.48       78.19       39.10
                 gas.
78594.........  Vent image, mult      ......  S             0401      3.1802      195.48       78.19       39.10
                 proj, gas.
78596.........  Lung differential     ......  S             0378      5.0975      313.33      125.33       62.67
                 function.
78599.........  Respiratory nuclear   ......  S             0401      3.1802      195.48       78.19       39.10
                 exam.
78600.........  Brain imaging, ltd    ......  S             0402      4.6418      285.32      114.12       57.06
                 static.
78601.........  Brain imaging, ltd w/ ......  S             0402      4.6418      285.32      114.12       57.06
                 flow.
78605.........  Brain imaging,        ......  S             0402      4.6418      285.32      114.12       57.06
                 complete.
78606.........  Brain imaging, compl  ......  S             0402      4.6418      285.32      114.12       57.06
                 w/flow.
78607.........  Brain imaging (3D)..  ......  S             0402      4.6418      285.32      114.12       57.06
78608.........  Brain imaging (PET).   CH...  S             0308     13.9166      855.43  ..........      171.09
78610.........  Brain flow imaging    ......  S             0402      4.6418      285.32      114.12       57.06
                 only.
78615.........  Cerebral vascular     ......  S             0402      4.6418      285.32      114.12       57.06
                 flow image.
78630.........  Cerebrospinal fluid   ......  S             0403      3.4923      214.66       83.35       42.93
                 scan.
78635.........  CSF ventriculography  ......  S             0403      3.4923      214.66       83.35       42.93
78645.........  CSF shunt evaluation  ......  S             0403      3.4923      214.66       83.35       42.93
78647.........  Cerebrospinal fluid   ......  S             0403      3.4923      214.66       83.35       42.93
                 scan.
78650.........  CSF leakage imaging.  ......  S             0403      3.4923      214.66       83.35       42.93
78660.........  Nuclear exam of tear  ......  S             0403      3.4923      214.66       83.35       42.93
                 flow.
78699.........  Nervous system        ......  S             0402      4.6418      285.32      114.12       57.06
                 nuclear exam.
78700.........  Kidney imaging,       ......  S             0404      3.4209      210.28       84.11       42.06
                 morphol.
78701.........  Kidney imaging with   ......  S             0404      3.4209      210.28       84.11       42.06
                 flow.
78704.........  Imaging renogram....   CH...  D       ..........  ..........  ..........  ..........  ..........
78707.........  Kflow/funct image w/  ......  S             0404      3.4209      210.28       84.11       42.06
                 o drug.
78708.........  Kflow/funct image w/  ......  S             0405      4.0378      248.20       98.77       49.64
                 drug.
78709.........  Kflow/funct image,    ......  S             0405      4.0378      248.20       98.77       49.64
                 multiple.
78710.........  Kidney imaging (3D).  ......  S             0404      3.4209      210.28       84.11       42.06
78715.........  Renal vascular flow    CH...  D       ..........  ..........  ..........  ..........  ..........
                 exam.
78725.........  Kidney function       ......  S             0389      1.3754       84.54       33.81       16.91
                 study.
78730.........  Urinary bladder       ......  X             0340      0.6102       37.51  ..........        7.50
                 retention.
78740.........  Ureteral reflux       ......  S             0404      3.4209      210.28       84.11       42.06
                 study.
78760.........  Testicular imaging..   CH...  D       ..........  ..........  ..........  ..........  ..........
78761.........  Testicular imaging w/ ......  S             0404      3.4209      210.28       84.11       42.06
                 flow.
78799.........  Genitourinary         ......  S             0404      3.4209      210.28       84.11       42.06
                 nuclear exam.
78800.........  Tumor imaging,        ......  S             0406      3.9934      245.47       98.18       49.09
                 limited area.
78801.........  Tumor imaging, mult   ......  S             0406      3.9934      245.47       98.18       49.09
                 areas.
78802.........  Tumor imaging, whole  ......  S             0406      3.9934      245.47       98.18       49.09
                 body.
78803.........  Tumor imaging (3D)..  ......  S             0406      3.9934      245.47       98.18       49.09
78804.........  Tumor imaging, whole   CH...  S             0408      5.9245      364.17  ..........       72.83
                 body.
78805.........  Abscess imaging, ltd  ......  S             0406      3.9934      245.47       98.18       49.09
                 area.
78806.........  Abscess imaging,      ......  S             0406      3.9934      245.47       98.18       49.09
                 whole body.
78807.........  Nuclear localization/ ......  S             0406      3.9934      245.47       98.18       49.09
                 abscess.
78811.........  Tumor imaging (pet),   CH...  S             0308     13.9166      855.43  ..........      171.09
                 limited.
78812.........  Tumor image (pet)/     CH...  S             0308     13.9166      855.43  ..........      171.09
                 skul-thigh.
78813.........  Tumor image (pet)      CH...  S             0308     13.9166      855.43  ..........      171.09
                 full body.
78814.........  Tumor image pet/ct,    CH...  S             1511  ..........      950.00  ..........      190.00
                 limited.
78815.........  Tumorimage pet/ct      CH...  S             1511  ..........      950.00  ..........      190.00
                 skul-thigh.
78816.........  Tumor image pet/ct     CH...  S             1511  ..........      950.00  ..........      190.00
                 full body.
78890.........  Nuclear medicine      ......  N       ..........  ..........  ..........  ..........  ..........
                 data proc.
78891.........  Nuclear med data      ......  N       ..........  ..........  ..........  ..........  ..........
                 proc.

[[Page 68352]]

 
78999.........  Nuclear diagnostic    ......  S             0389      1.3754       84.54       33.81       16.91
                 exam.
79005.........  Nuclear rx, oral      ......  S             0407      3.1779      195.34       78.13       39.07
                 admin.
79101.........  Nuclear rx, iv admin  ......  S             0407      3.1779      195.34       78.13       39.07
79200.........  Nuclear rx, intracav   CH...  S             0413      5.2957      325.52  ..........       65.10
                 admin.
79300.........  Nuclr rx, interstit   ......  S             0407      3.1779      195.34       78.13       39.07
                 colloid.
79403.........  Hematopoietic          CH...  S             0413      5.2957      325.52  ..........       65.10
                 nuclear tx.
79440.........  Nuclear rx, intra-     CH...  S             0413      5.2957      325.52  ..........       65.10
                 articular.
79445.........  Nuclear rx, intra-    ......  S             0407      3.1779      195.34       78.13       39.07
                 arterial.
79999.........  Nuclear medicine      ......  S             0407      3.1779      195.34       78.13       39.07
                 therapy.
80103.........  Drug analysis,        ......  N       ..........  ..........  ..........  ..........  ..........
                 tissue prep.
80500.........  Lab pathology         ......  X             0433      0.2557       15.72        5.93        3.14
                 consultation.
80502.........  Lab pathology         ......  X             0342      0.0824        5.06        2.02        1.01
                 consultation.
81099.........  Urinalysis test       ......  X             0342      0.0824        5.06        2.02        1.01
                 procedure.
82107.........  Alpha-fetoprotein l3   NI...  A       ..........  ..........  ..........  ..........  ..........
83698.........  Assay lipoprotein      NI...  A       ..........  ..........  ..........  ..........  ..........
                 pla2.
83913.........  Molecular, rna         NI...  A       ..........  ..........  ..........  ..........  ..........
                 stabilization.
84999.........  Clinical chemistry    ......  X             0342      0.0824        5.06        2.02        1.01
                 test.
85097.........  Bone marrow           ......  X             0343      0.5211       32.03       10.84        6.41
                 interpretation.
85396.........  Clotting assay,       ......  N       ..........  ..........  ..........  ..........  ..........
                 whole blood.
85999.........  Hematology procedure  ......  X             0342      0.0824        5.06        2.02        1.01
86077.........  Physician blood bank  ......  X             0433      0.2557       15.72        5.93        3.14
                 service.
86078.........  Physician blood bank  ......  X             0343      0.5211       32.03       10.84        6.41
                 service.
86079.........  Physician blood bank  ......  X             0433      0.2557       15.72        5.93        3.14
                 service.
86485.........  Skin test, candida..  ......  X             0341      0.0914        5.62        2.24        1.12
86490.........  Coccidioidomycosis    ......  X             0341      0.0914        5.62        2.24        1.12
                 skin test.
86510.........  Histoplasmosis skin   ......  X             0341      0.0914        5.62        2.24        1.12
                 test.
86580.........  TB intradermal test.  ......  X             0341      0.0914        5.62        2.24        1.12
86788.........  West nile virus ab,    NI...  A       ..........  ..........  ..........  ..........  ..........
                 igm.
86789.........  West nile virus        NI...  A       ..........  ..........  ..........  ..........  ..........
                 antibody.
86849.........  Immunology procedure  ......  X             0342      0.0824        5.06        2.02        1.01
86850.........  RBC antibody screen.  ......  X             0345      0.2178       13.39        2.87        2.68
86860.........  RBC antibody elution  ......  X             0346      0.3484       21.42        4.39        4.28
86870.........  RBC antibody          ......  X             0346      0.3484       21.42        4.39        4.28
                 identification.
86880.........  Coombs test, direct.  ......  X             0409      0.1227        7.54        2.20        1.51
86885.........  Coombs test,          ......  X             0409      0.1227        7.54        2.20        1.51
                 indirect, qual.
86886.........  Coombs test,          ......  X             0409      0.1227        7.54        2.20        1.51
                 indirect, titer.
86890.........  Autologous blood      ......  X             0347      0.7423       45.63       11.28        9.13
                 process.
86891.........  Autologous blood, op  ......  X             0346      0.3484       21.42        4.39        4.28
                 salvage.
86900.........  Blood typing, ABO...  ......  X             0409      0.1227        7.54        2.20        1.51
86901.........  Blood typing, Rh (D)  ......  X             0409      0.1227        7.54        2.20        1.51
86903.........  Blood typing,         ......  X             0345      0.2178       13.39        2.87        2.68
                 antigen screen.
86904.........  Blood typing,         ......  X             0346      0.3484       21.42        4.39        4.28
                 patient serum.
86905.........  Blood typing, RBC     ......  X             0345      0.2178       13.39        2.87        2.68
                 antigens.
86906.........  Blood typing, Rh      ......  X             0345      0.2178       13.39        2.87        2.68
                 phenotype.
86920.........  Compatibility test,   ......  X             0346      0.3484       21.42        4.39        4.28
                 spin.
86921.........  Compatibility test,   ......  X             0345      0.2178       13.39        2.87        2.68
                 incubate.
86922.........  Compatibility test,   ......  X             0346      0.3484       21.42        4.39        4.28
                 antiglob.
86923.........  Compatibility test,   ......  X             0345      0.2178       13.39        2.87        2.68
                 electric.
86927.........  Plasma, fresh frozen  ......  X             0345      0.2178       13.39        2.87        2.68
86930.........  Frozen blood prep...  ......  X             0347      0.7423       45.63       11.28        9.13
86931.........  Frozen blood thaw...  ......  X             0347      0.7423       45.63       11.28        9.13
86932.........  Frozen blood freeze/  ......  X             0347      0.7423       45.63       11.28        9.13
                 thaw.
86945.........  Blood product/        ......  X             0345      0.2178       13.39        2.87        2.68
                 irradiation.
86950.........  Leukacyte             ......  X             0345      0.2178       13.39        2.87        2.68
                 transfusion.
86960.........  Vol reduction of      ......  X             0345      0.2178       13.39        2.87        2.68
                 blood/prod.
86965.........  Pooling blood          CH...  X             0346      0.3484       21.42        4.39        4.28
                 platelets.
86970.........  RBC pretreatment....  ......  X             0345      0.2178       13.39        2.87        2.68
86971.........  RBC pretreatment....  ......  X             0345      0.2178       13.39        2.87        2.68
86972.........  RBC pretreatment....  ......  X             0346      0.3484       21.42        4.39        4.28
86975.........  RBC pretreatment,      CH...  X             0346      0.3484       21.42        4.39        4.28
                 serum.
86976.........  RBC pretreatment,     ......  X             0345      0.2178       13.39        2.87        2.68
                 serum.
86977.........  RBC pretreatment,      CH...  X             0346      0.3484       21.42        4.39        4.28
                 serum.
86978.........  RBC pretreatment,      CH...  X             0346      0.3484       21.42        4.39        4.28
                 serum.
86985.........  Split blood or        ......  X             0345      0.2178       13.39        2.87        2.68
                 products.
86999.........  Transfusion           ......  X             0345      0.2178       13.39        2.87        2.68
                 procedure.
87305.........  Aspergillus ag, eia.   NI...  A       ..........  ..........  ..........  ..........  ..........
87498.........  Enterovirus, dna,      NI...  A       ..........  ..........  ..........  ..........  ..........
                 amp probe.
87640.........  Staph a, dna, amp      NI...  A       ..........  ..........  ..........  ..........  ..........
                 probe.
87641.........  Mr-staph, dna, amp     NI...  A       ..........  ..........  ..........  ..........  ..........
                 probe.
87653.........  Strep b, dna, amp      NI...  A       ..........  ..........  ..........  ..........  ..........
                 probe.

[[Page 68353]]

 
87808.........  Trichomonas assay w/   NI...  A       ..........  ..........  ..........  ..........  ..........
                 optic.
87999.........  Microbiology          ......  X             0342      0.0824        5.06        2.02        1.01
                 procedure.
88104.........  Cytopath fl nongyn,   ......  X             0433      0.2557       15.72        5.93        3.14
                 smears.
88106.........  Cytopath fl nongyn,   ......  X             0433      0.2557       15.72        5.93        3.14
                 filter.
88107.........  Cytopath fl nongyn,   ......  X             0433      0.2557       15.72        5.93        3.14
                 sm/fltr.
88108.........  Cytopath,             ......  X             0433      0.2557       15.72        5.93        3.14
                 concentrate tech.
88112.........  Cytopath, cell        ......  X             0343      0.5211       32.03       10.84        6.41
                 enhance tech.
88125.........  Forensic               CH...  X             0433      0.2557       15.72        5.93        3.14
                 cytopathology.
88141.........  Cytopath, c/v,        ......  N       ..........  ..........  ..........  ..........  ..........
                 interpret.
88160.........  Cytopath smear,       ......  X             0433      0.2557       15.72        5.93        3.14
                 other source.
88161.........  Cytopath smear,       ......  X             0433      0.2557       15.72        5.93        3.14
                 other source.
88162.........  Cytopath smear,       ......  X             0433      0.2557       15.72        5.93        3.14
                 other source.
88172.........  Cytopathology eval    ......  X             0343      0.5211       32.03       10.84        6.41
                 of fna.
88173.........  Cytopath eval, fna,   ......  X             0343      0.5211       32.03       10.84        6.41
                 report.
88182.........  Cell marker study...   CH...  X             0343      0.5211       32.03       10.84        6.41
88184.........  Flowcytometry/ tc, 1   CH...  X             0433      0.2557       15.72        5.93        3.14
                 marker.
88185.........  Flowcytometry/tc,      CH...  X             0433      0.2557       15.72        5.93        3.14
                 add-on.
88187.........  Flowcytometry/read,   ......  X             0433      0.2557       15.72        5.93        3.14
                 2-8.
88188.........  Flowcytometry/read,   ......  X             0433      0.2557       15.72        5.93        3.14
                 9-15.
88189.........  Flowcytometry/read,   ......  X             0343      0.5211       32.03       10.84        6.41
                 16 & >.
88199.........  Cytopathology         ......  X             0342      0.0824        5.06        2.02        1.01
                 procedure.
88299.........  Cytogenetic study...  ......  X             0342      0.0824        5.06        2.02        1.01
88300.........  Surgical path, gross  ......  X             0433      0.2557       15.72        5.93        3.14
88302.........  Tissue exam by        ......  X             0433      0.2557       15.72        5.93        3.14
                 pathologist.
88304.........  Tissue exam by        ......  X             0343      0.5211       32.03       10.84        6.41
                 pathologist.
88305.........  Tissue exam by        ......  X             0343      0.5211       32.03       10.84        6.41
                 pathologist.
88307.........  Tissue exam by        ......  X             0344      0.7927       48.73       15.66        9.75
                 pathologist.
88309.........  Tissue exam by        ......  X             0344      0.7927       48.73       15.66        9.75
                 pathologist.
88311.........  Decalcify tissue....   CH...  X             0433      0.2557       15.72        5.93        3.14
88312.........  Special stains......  ......  X             0433      0.2557       15.72        5.93        3.14
88313.........  Special stains......  ......  X             0433      0.2557       15.72        5.93        3.14
88314.........  Histochemical stain.  ......  X             0342      0.0824        5.06        2.02        1.01
88318.........  Chemical              ......  X             0433      0.2557       15.72        5.93        3.14
                 histochemistry.
88319.........  Enzyme                ......  X             0343      0.5211       32.03       10.84        6.41
                 histochemistry.
88321.........  Microslide            ......  X             0433      0.2557       15.72        5.93        3.14
                 consultation.
88323.........  Microslide            ......  X             0343      0.5211       32.03       10.84        6.41
                 consultation.
88325.........  Comprehensive review  ......  X             0344      0.7927       48.73       15.66        9.75
                 of data.
88329.........  Path consult introp.  ......  X             0433      0.2557       15.72        5.93        3.14
88331.........  Path consult          ......  X             0343      0.5211       32.03       10.84        6.41
                 intraop, 1 bloc.
88332.........  Path consult          ......  X             0433      0.2557       15.72        5.93        3.14
                 intraop,
                 add[AElig]l.
88333.........  Intraop cyto path     ......  X             0343      0.5211       32.03       10.84        6.41
                 consult, 1.
88334.........  Intraop cyto path     ......  X             0433      0.2557       15.72        5.93        3.14
                 consult, 2.
88342.........  Immunohistochemistry  ......  X             0343      0.5211       32.03       10.84        6.41
88346.........  Immunofluorescent     ......  X             0343      0.5211       32.03       10.84        6.41
                 study.
88347.........  Immunofluorescent     ......  X             0343      0.5211       32.03       10.84        6.41
                 study.
88348.........  Electron microscopy.  ......  X             0661      2.5255      155.24       62.09       31.05
88349.........  Scanning electron     ......  X             0661      2.5255      155.24       62.09       31.05
                 microscopy.
88355.........  Analysis, skeletal    ......  X             0343      0.5211       32.03       10.84        6.41
                 muscle.
88356.........  Analysis, nerve.....  ......  X             0344      0.7927       48.73       15.66        9.75
88358.........  Analysis, tumor.....  ......  X             0344      0.7927       48.73       15.66        9.75
88360.........  Tumor                  CH...  X             0343      0.5211       32.03       10.84        6.41
                 immunohistochem/
                 manual.
88361.........  Tumor                 ......  X             0344      0.7927       48.73       15.66        9.75
                 immunohistochem/
                 comput.
88362.........  Nerve teasing         ......  X             0344      0.7927       48.73       15.66        9.75
                 preparations.
88365.........  Insitu hybridization  ......  X             0344      0.7927       48.73       15.66        9.75
                 (fish).
88367.........  Insitu                ......  X             0344      0.7927       48.73       15.66        9.75
                 hybridization, auto.
88368.........  Insitu                ......  X             0344      0.7927       48.73       15.66        9.75
                 hybridization,
                 manual.
88380.........  Microdissection.....  ......  N       ..........  ..........  ..........  ..........  ..........
88384.........  Eval molecular        ......  X             0433      0.2557       15.72        5.93        3.14
                 probes, 11-50.
88385.........  Eval molecul probes,  ......  X             0343      0.5211       32.03       10.84        6.41
                 51-250.
88386.........  Eval molecul probes,  ......  X             0344      0.7927       48.73       15.66        9.75
                 251-500.
88399.........  Surgical pathology    ......  X             0342      0.0824        5.06        2.02        1.01
                 procedure.
89049.........  Chct for mal          ......  X             0343      0.5211       32.03       10.84        6.41
                 hyperthermia.
89100.........  Sample intestinal     ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89105.........  Sample intestinal     ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89130.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89132.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89135.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89136.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89140.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.
89141.........  Sample stomach        ......  X             0360      1.4154       87.00       33.88       17.40
                 contents.

[[Page 68354]]

 
89220.........  Sputum specimen       ......  X             0343      0.5211       32.03       10.84        6.41
                 collection.
89230.........  Collect sweat for     ......  X             0433      0.2557       15.72        5.93        3.14
                 test.
89240.........  Pathology lab         ......  X             0342      0.0824        5.06        2.02        1.01
                 procedure.
89250.........  Cultr oocyte/embryo   ......  X             0348      0.8321       51.15  ..........       10.23
                 <4 days.
89251.........  Cultr oocyte/embryo   ......  X             0348      0.8321       51.15  ..........       10.23
                 <4 days.
89253.........  Embryo hatching.....  ......  X             0348      0.8321       51.15  ..........       10.23
89254.........  Oocyte                ......  X             0348      0.8321       51.15  ..........       10.23
                 identification.
89255.........  Prepare embryo for    ......  X             0348      0.8321       51.15  ..........       10.23
                 transfer.
89257.........  Sperm identification  ......  X             0348      0.8321       51.15  ..........       10.23
89258.........  Cryopreservation;     ......  X             0348      0.8321       51.15  ..........       10.23
                 embryo(s).
89259.........  Cryopreservation,     ......  X             0348      0.8321       51.15  ..........       10.23
                 sperm.
89260.........  Sperm isolation,      ......  X             0348      0.8321       51.15  ..........       10.23
                 simple.
89261.........  Sperm isolation,      ......  X             0348      0.8321       51.15  ..........       10.23
                 complex.
89264.........  Identify sperm        ......  X             0348      0.8321       51.15  ..........       10.23
                 tissue.
89268.........  Insemination of       ......  X             0348      0.8321       51.15  ..........       10.23
                 oocytes.
89272.........  Extended culture of   ......  X             0348      0.8321       51.15  ..........       10.23
                 oocytes.
89280.........  Assist oocyte         ......  X             0348      0.8321       51.15  ..........       10.23
                 fertilization.
89281.........  Assist oocyte         ......  X             0348      0.8321       51.15  ..........       10.23
                 fertilization.
89290.........  Biopsy, oocyte polar  ......  X             0348      0.8321       51.15  ..........       10.23
                 body.
89291.........  Biopsy, oocyte polar  ......  X             0348      0.8321       51.15  ..........       10.23
                 body.
89335.........  Cryopreserve          ......  X             0348      0.8321       51.15  ..........       10.23
                 testicular tiss.
89342.........  Storage/year;         ......  X             0348      0.8321       51.15  ..........       10.23
                 embryo(s).
89343.........  Storage/year; sperm/  ......  X             0348      0.8321       51.15  ..........       10.23
                 semen.
89344.........  Storage/year; reprod  ......  X             0348      0.8321       51.15  ..........       10.23
                 tissue.
89346.........  Storage/year;         ......  X             0348      0.8321       51.15  ..........       10.23
                 oocyte(s).
89352.........  Thawing               ......  X             0348      0.8321       51.15  ..........       10.23
                 cryopresrved;
                 embryo.
89353.........  Thawing               ......  X             0348      0.8321       51.15  ..........       10.23
                 cryopresrved; sperm.
89354.........  Thaw cryoprsvrd;      ......  X             0348      0.8321       51.15  ..........       10.23
                 reprod tiss.
89356.........  Thawing               ......  X             0348      0.8321       51.15  ..........       10.23
                 cryopresrved;
                 oocyte.
90296.........  Diphtheria antitoxin  ......  N       ..........  ..........  ..........  ..........  ..........
90371.........  Hep b ig, im........  ......  K             1630  ..........      119.06  ..........       23.81
90375.........  Rabies ig, im/sc....  ......  K             9133  ..........       64.53  ..........       12.91
90376.........  Rabies ig, heat       ......  K             9134  ..........       68.24  ..........       13.65
                 treated.
90385.........  Rh ig, minidose, im.  ......  N       ..........  ..........  ..........  ..........  ..........
90393.........  Vaccina ig, im......  ......  N       ..........  ..........  ..........  ..........  ..........
90396.........  Varicella-zoster ig,  ......  K             9135  ..........      140.92  ..........       28.18
                 im.
90471.........  Immunization admin..   CH...  S             0437      0.3945       24.25  ..........        4.85
90472.........  Immunization admin,    CH...  S             0436      0.1809       11.12  ..........        2.22
                 each add.
90473.........  Immune admin oral/     CH...  S             0436      0.1809       11.12  ..........        2.22
                 nasal.
90474.........  Immune admin oral/     CH...  S             0436      0.1809       11.12  ..........        2.22
                 nasal addl.
90476.........  Adenovirus vaccine,    CH...  N       ..........  ..........  ..........  ..........  ..........
                 type 4.
90477.........  Adenovirus vaccine,   ......  N       ..........  ..........  ..........  ..........  ..........
                 type 7.
90581.........  Anthrax vaccine, sc.   CH...  N       ..........  ..........  ..........  ..........  ..........
90585.........  Bcg vaccine, percut.  ......  K             9137  ..........      117.39  ..........       23.48
90632.........  Hep a vaccine, adult  ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90633.........  Hep a vacc, ped/      ......  N       ..........  ..........  ..........  ..........  ..........
                 adol, 2 dose.
90634.........  Hep a vacc, ped/      ......  N       ..........  ..........  ..........  ..........  ..........
                 adol, 3 dose.
90636.........  Hep a/hep b vacc,      CH...  N       ..........  ..........  ..........  ..........  ..........
                 adult im.
90645.........  Hib vaccine, hboc,    ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90646.........  Hib vaccine, prp-d,   ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90647.........  Hib vaccine, prp-     ......  N       ..........  ..........  ..........  ..........  ..........
                 omp, im.
90648.........  Hib vaccine, prp-t,   ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90649.........  Hpapilloma vacc 3      CH...  B       ..........  ..........  ..........  ..........  ..........
                 dose im.
90665.........  Lyme disease           CH...  N       ..........  ..........  ..........  ..........  ..........
                 vaccine, im.
90675.........  Rabies vaccine, im..  ......  K             9139  ..........      157.74  ..........       31.55
90676.........  Rabies vaccine, id..  ......  K             9140  ..........      166.16  ..........       33.23
90680.........  Rotovirus vacc 3      ......  N       ..........  ..........  ..........  ..........  ..........
                 dose, oral.
90690.........  Typhoid vaccine,      ......  N       ..........  ..........  ..........  ..........  ..........
                 oral.
90691.........  Typhoid vaccine, im.  ......  N       ..........  ..........  ..........  ..........  ..........
90692.........  Typhoid vaccine, h-   ......  N       ..........  ..........  ..........  ..........  ..........
                 p, sc/id.
90693.........  Typhoid vaccine,       CH...  B       ..........  ..........  ..........  ..........  ..........
                 akd, sc.
90698.........  Dtap-hib-ip vaccine,  ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90700.........  Dtap vaccine, < 7     ......  N       ..........  ..........  ..........  ..........  ..........
                 yrs, im.
90701.........  Dtp vaccine, im.....  ......  N       ..........  ..........  ..........  ..........  ..........
90702.........  Dt vaccine < 7, im..  ......  N       ..........  ..........  ..........  ..........  ..........
90703.........  Tetanus vaccine, im.  ......  N       ..........  ..........  ..........  ..........  ..........
90704.........  Mumps vaccine, sc...  ......  N       ..........  ..........  ..........  ..........  ..........
90705.........  Measles vaccine, sc.  ......  N       ..........  ..........  ..........  ..........  ..........
90706.........  Rubella vaccine, sc.  ......  N       ..........  ..........  ..........  ..........  ..........
90707.........  Mmr vaccine, sc.....  ......  N       ..........  ..........  ..........  ..........  ..........

[[Page 68355]]

 
90708.........  Measles-rubella       ......  K             9141  ..........       60.82  ..........       12.16
                 vaccine, sc.
90710.........  Mmrv vaccine, sc....  ......  N       ..........  ..........  ..........  ..........  ..........
90712.........  Oral poliovirus       ......  N       ..........  ..........  ..........  ..........  ..........
                 vaccine.
90713.........  Poliovirus, ipv, sc/  ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90714.........  Td vaccine no prsrv    CH...  N       ..........  ..........  ..........  ..........  ..........
                 [gE] 7 im.
90715.........  Tdap vaccine >7 im..  ......  N       ..........  ..........  ..........  ..........  ..........
90716.........  Chicken pox vaccine,   CH...  B       ..........  ..........  ..........  ..........  ..........
                 sc.
90717.........  Yellow fever           CH...  N       ..........  ..........  ..........  ..........  ..........
                 vaccine, sc.
90718.........  Td vaccine > 7, im..  ......  N       ..........  ..........  ..........  ..........  ..........
90719.........  Diphtheria vaccine,   ......  N       ..........  ..........  ..........  ..........  ..........
                 im.
90720.........  Dtp/hib vaccine, im.   CH...  K             3032  ..........       45.01  ..........        9.00
90721.........  Dtap/hib vaccine, im  ......  N       ..........  ..........  ..........  ..........  ..........
90725.........  Cholera vaccine,      ......  N       ..........  ..........  ..........  ..........  ..........
                 injectable.
90727.........  Plague vaccine, im..   CH...  K             0744  ..........      150.00  ..........       30.00
90733.........  Meningococcal         ......  K             9143  ..........       84.46  ..........       16.89
                 vaccine, sc.
90734.........  Meningococcal         ......  K             9145  ..........       53.71  ..........       10.74
                 vaccine, im.
90735.........  Encephalitis          ......  K             9144  ..........       96.22  ..........       19.24
                 vaccine, sc.
90736.........  Zoster vacc, sc.....   CH...  B       ..........  ..........  ..........  ..........  ..........
90749.........  Vaccine toxoid......  ......  N       ..........  ..........  ..........  ..........  ..........
90760.........  Hydration iv           CH...  S             0440       1.809      111.20  ..........       22.24
                 infusion, init.
90761.........  Hydrate iv infusion,   CH...  S             0437      0.3945       24.25  ..........        4.85
                 add-on.
90765.........  Ther/proph/diag iv     CH...  S             0440       1.809      111.20  ..........       22.24
                 inf, init.
90766.........  Ther/proph/dg iv       CH...  S             0437      0.3945       24.25  ..........        4.85
                 inf, add-on.
90767.........  Tx/proph/dg addl seq   CH...  S             0437      0.3945       24.25  ..........        4.85
                 iv inf.
90768.........  Ther/diag concurrent   CH...  N       ..........  ..........  ..........  ..........  ..........
                 inf.
90772.........  Ther/proph/diag inj,   CH...  S             0437      0.3945       24.25  ..........        4.85
                 sc/im.
90773.........  Ther/proph/diag inj,   CH...  S             0438      0.7942       48.82  ..........        9.76
                 ia.
90774.........  Ther/proph/diag inj,   CH...  S             0438      0.7942       48.82  ..........        9.76
                 iv push.
90775.........  Ther/proph/diag inj    CH...  S             0438      0.7942       48.82  ..........        9.76
                 add-on.
90779.........  Ther/prop/diag inj/    CH...  S             0436      0.1809       11.12  ..........        2.22
                 inf proc.
90801.........  Psy dx interview....  ......  S             0323      1.7066      104.90  ..........       20.98
90802.........  Intac psy dx          ......  S             0323      1.7066      104.90  ..........       20.98
                 interview.
90804.........  Psytx, office, 20-30  ......  S             0322      1.1798       72.52  ..........       14.50
                 min.
90805.........  Psytx, off, 20-30     ......  S             0322      1.1798       72.52  ..........       14.50
                 min w/e&m.
90806.........  Psytx, off, 45-50     ......  S             0323      1.7066      104.90  ..........       20.98
                 min.
90807.........  Psytx, off, 45-50     ......  S             0323      1.7066      104.90  ..........       20.98
                 min w/e&m.
90808.........  Psytx, office, 75-80  ......  S             0323      1.7066      104.90  ..........       20.98
                 min.
90809.........  Psytx, off, 75-80, w/ ......  S             0323      1.7066      104.90  ..........       20.98
                 e&m.
90810.........  Intac psytx, off, 20- ......  S             0322      1.1798       72.52  ..........       14.50
                 30 min.
90811.........  Intac psytx, 20-30,   ......  S             0322      1.1798       72.52  ..........       14.50
                 w/e&m.
90812.........  Intac psytx, off, 45- ......  S             0323      1.7066      104.90  ..........       20.98
                 50 min.
90813.........  Intac psytx, 45-50    ......  S             0323      1.7066      104.90  ..........       20.98
                 min w/e&m.
90814.........  Intac psytx, off, 75- ......  S             0323      1.7066      104.90  ..........       20.98
                 80 min.
90815.........  Intac psytx, 75-80 w/ ......  S             0323      1.7066      104.90  ..........       20.98
                 e&m.
90816.........  Psytx, hosp, 20-30    ......  S             0322      1.1798       72.52  ..........       14.50
                 min.
90817.........  Psytx, hosp, 20-30    ......  S             0322      1.1798       72.52  ..........       14.50
                 min w/e&m.
90818.........  Psytx, hosp, 45-50    ......  S             0323      1.7066      104.90  ..........       20.98
                 min.
90819.........  Psytx, hosp, 45-50    ......  S             0323      1.7066      104.90  ..........       20.98
                 min w/e&m.
90821.........  Psytx, hosp, 75-80    ......  S             0323      1.7066      104.90  ..........       20.98
                 min.
90822.........  Psytx, hosp, 75-80    ......  S             0323      1.7066      104.90  ..........       20.98
                 min w/e&m.
90823.........  Intac psytx, hosp,    ......  S             0322      1.1798       72.52  ..........       14.50
                 20-30 min.
90824.........  Intac psytx, hsp 20-  ......  S             0322      1.1798       72.52  ..........       14.50
                 30 w/e&m.
90826.........  Intac psytx, hosp,    ......  S             0323      1.7066      104.90  ..........       20.98
                 45-50 min.
90827.........  Intac psytx, hsp 45-  ......  S             0323      1.7066      104.90  ..........       20.98
                 50 w/e&m.
90828.........  Intac psytx, hosp,    ......  S             0323      1.7066      104.90  ..........       20.98
                 75-80 min.
90829.........  Intac psytx, hsp 75-  ......  S             0323      1.7066      104.90  ..........       20.98
                 80 w/e&m.
90845.........  Psychoanalysis......  ......  S             0323      1.7066      104.90  ..........       20.98
90846.........  Family psytx w/o      ......  S             0324      2.1633      132.97  ..........       26.59
                 patient.
90847.........  Family psytx w/       ......  S             0324      2.1633      132.97  ..........       26.59
                 patient.
90849.........  Multiple family       ......  S             0325      1.0765       66.17       14.47       13.23
                 group psytx.
90853.........  Group psychotherapy.  ......  S             0325      1.0765       66.17       14.47       13.23
90857.........  Intac group psytx...  ......  S             0325      1.0765       66.17       14.47       13.23
90862.........  Medication            ......  X             0374      1.1418       70.18  ..........       14.04
                 management.
90865.........  Narcosynthesis......  ......  S             0323      1.7066      104.90  ..........       20.98
90870.........  Electroconvulsive     ......  S             0320      5.5676      342.23       80.06       68.45
                 therapy.
90880.........  Hypnotherapy........  ......  S             0323      1.7066      104.90  ..........       20.98
90885.........  Psy evaluation of     ......  N       ..........  ..........  ..........  ..........  ..........
                 records.
90887.........  Consultation with     ......  N       ..........  ..........  ..........  ..........  ..........
                 family.
90889.........  Preparation of        ......  N       ..........  ..........  ..........  ..........  ..........
                 report.
90899.........  Psychiatric service/  ......  S             0322      1.1798       72.52  ..........       14.50
                 therapy.

[[Page 68356]]

 
90911.........  Biofeedback peri/uro/ ......  S             0321      1.3384       82.27       21.72       16.45
                 rectal.
90935.........  Hemodialysis, one     ......  S             0170      6.6089      406.24  ..........       81.25
                 evaluation.
90940.........  Hemodialysis access   ......  N       ..........  ..........  ..........  ..........  ..........
                 study.
90945.........  Dialysis, one         ......  S             0170      6.6089      406.24  ..........       81.25
                 evaluation.
91000.........  Esophageal            ......  X             0361      3.8887      239.03       83.23       47.81
                 intubation.
91010.........  Esophagus motility    ......  X             0361      3.8887      239.03       83.23       47.81
                 study.
91011.........  Esophagus motility    ......  X             0361      3.8887      239.03       83.23       47.81
                 study.
91012.........  Esophagus motility    ......  X             0361      3.8887      239.03       83.23       47.81
                 study.
91020.........  Gastric motility      ......  X             0361      3.8887      239.03       83.23       47.81
                 studies.
91022.........  Duodenal motility     ......  X             0361      3.8887      239.03       83.23       47.81
                 study.
91030.........  Acid perfusion of     ......  X             0361      3.8887      239.03       83.23       47.81
                 esophagus.
91034.........  Gastroesophageal      ......  X             0361      3.8887      239.03       83.23       47.81
                 reflux test.
91035.........  G-esoph reflx tst w/   CH...  X             0361      3.8887      239.03       83.23       47.81
                 electrod.
91037.........  Esoph imped function  ......  X             0361      3.8887      239.03       83.23       47.81
                 test.
91038.........  Esoph imped funct     ......  X             0361      3.8887      239.03       83.23       47.81
                 test > 1h.
91040.........  Esoph balloon         ......  X             0360      1.4154       87.00       33.88       17.40
                 distension tst.
91052.........  Gastric analysis      ......  X             0361      3.8887      239.03       83.23       47.81
                 test.
91055.........  Gastric intubation    ......  X             0360      1.4154       87.00       33.88       17.40
                 for smear.
91060.........  Gastric saline load    CH...  D       ..........  ..........  ..........  ..........  ..........
                 test.
91065.........  Breath hydrogen test  ......  X             0360      1.4154       87.00       33.88       17.40
91100.........  Pass intestine        ......  X             0360      1.4154       87.00       33.88       17.40
                 bleeding tube.
91105.........  Gastric intubation    ......  X             0360      1.4154       87.00       33.88       17.40
                 treatment.
91110.........  Gi tract capsule      ......  T             0142      9.4946      583.61      152.78      116.72
                 endoscopy.
91111.........  Esophageal capsule     NI...  T             0141      8.3175      511.26      143.38      102.25
                 endoscopy.
91120.........  Rectal sensation       CH...  T             0126      1.0887       66.92       16.45       13.38
                 test.
91122.........  Anal pressure record   CH...  T             0164      2.1393      131.50  ..........       26.30
91123.........  Irrigate fecal        ......  N       ..........  ..........  ..........  ..........  ..........
                 impaction.
91132.........  Electrogastrography.  ......  X             0360      1.4154       87.00       33.88       17.40
91133.........  Electrogastrography   ......  X             0360      1.4154       87.00       33.88       17.40
                 w/test.
91299.........  Gastroenterology      ......  X             0360      1.4154       87.00       33.88       17.40
                 procedure.
92002.........  Eye exam, new          CH...  V             0605       0.984       60.48  ..........       12.10
                 patient.
92004.........  Eye exam, new          CH...  V             0606      1.3646       83.88  ..........       16.78
                 patient.
92012.........  Eye exam established   CH...  V             0604      0.8242       50.66  ..........       10.13
                 pat.
92014.........  Eye exam & treatment   CH...  V             0605       0.984       60.48  ..........       12.10
92018.........  New eye exam &        ......  T             0699     14.3845      884.19  ..........      176.84
                 treatment.
92019.........  Eye exam & treatment  ......  T             0699     14.3845      884.19  ..........      176.84
92020.........  Special eye           ......  S             0230      0.7898       48.55       14.97        9.71
                 evaluation.
92025.........  Corneal topography..   NI...  S             0698      1.1607       71.35  ..........       14.27
92060.........  Special eye           ......  S             0230      0.7898       48.55       14.97        9.71
                 evaluation.
92065.........  Orthoptic/pleoptic     CH...  S             0230      0.7898       48.55       14.97        9.71
                 training.
92070.........  Fitting of contact    ......  N       ..........  ..........  ..........  ..........  ..........
                 lens.
92081.........  Visual field          ......  S             0230      0.7898       48.55       14.97        9.71
                 examination(s).
92082.........  Visual field          ......  S             0230      0.7898       48.55       14.97        9.71
                 examination(s).
92083.........  Visual field          ......  S             0230      0.7898       48.55       14.97        9.71
                 examination(s).
92100.........  Serial tonometry      ......  N       ..........  ..........  ..........  ..........  ..........
                 exam(s).
92120.........  Tonography & eye      ......  S             0230      0.7898       48.55       14.97        9.71
                 evaluation.
92130.........  Water provocation     ......  S             0230      0.7898       48.55       14.97        9.71
                 tonography.
92135.........  Opthalmic dx imaging  ......  S             0230      0.7898       48.55       14.97        9.71
92136.........  Ophthalmic biometry.  ......  S             0698      1.1607       71.35  ..........       14.27
92140.........  Glaucoma provocative   CH...  S             0230      0.7898       48.55       14.97        9.71
                 tests.
92225.........  Special eye exam,      CH...  S             0230      0.7898       48.55       14.97        9.71
                 initial.
92226.........  Special eye exam,      CH...  S             0230      0.7898       48.55       14.97        9.71
                 subsequent.
92230.........  Eye exam with photos   CH...  S             0231      2.1451      131.86  ..........       26.37
92235.........  Eye exam with photos  ......  S             0231      2.1451      131.86  ..........       26.37
92240.........  Icg angiography.....  ......  S             0231      2.1451      131.86  ..........       26.37
92250.........  Eye exam with photos  ......  S             0230      0.7898       48.55       14.97        9.71
92260.........  Ophthalmoscopy/        CH...  S             0230      0.7898       48.55       14.97        9.71
                 dynamometry.
92265.........  Eye muscle            ......  S             0230      0.7898       48.55       14.97        9.71
                 evaluation.
92270.........  Electro-oculography.  ......  S             0230      0.7898       48.55       14.97        9.71
92275.........  Electroretinography.  ......  S             0231      2.1451      131.86  ..........       26.37
92283.........  Color vision          ......  S             0230      0.7898       48.55       14.97        9.71
                 examination.
92284.........  Dark adaptation eye   ......  S             0698      1.1607       71.35  ..........       14.27
                 exam.
92285.........  Eye photography.....  ......  S             0230      0.7898       48.55       14.97        9.71
92286.........  Internal eye          ......  S             0698      1.1607       71.35  ..........       14.27
                 photography.
92287.........  Internal eye          ......  S             0698      1.1607       71.35  ..........       14.27
                 photography.
92311.........  Contact lens fitting  ......  X             0362      0.5865       36.05  ..........        7.21
92312.........  Contact lens fitting  ......  X             0362      0.5865       36.05  ..........        7.21
92313.........  Contact lens fitting  ......  X             0362      0.5865       36.05  ..........        7.21
92315.........  Prescription of       ......  X             0362      0.5865       36.05  ..........        7.21
                 contact lens.
92316.........  Prescription of       ......  X             0362      0.5865       36.05  ..........        7.21
                 contact lens.

[[Page 68357]]

 
92317.........  Prescription of       ......  X             0362      0.5865       36.05  ..........        7.21
                 contact lens.
92325.........  Modification of       ......  X             0362      0.5865       36.05  ..........        7.21
                 contact lens.
92326.........  Replacement of        ......  X             0362      0.5865       36.05  ..........        7.21
                 contact lens.
92352.........  Special spectacles    ......  X             0362      0.5865       36.05  ..........        7.21
                 fitting.
92353.........  Special spectacles    ......  X             0362      0.5865       36.05  ..........        7.21
                 fitting.
92354.........  Special spectacles    ......  X             0362      0.5865       36.05  ..........        7.21
                 fitting.
92355.........  Special spectacles    ......  X             0362      0.5865       36.05  ..........        7.21
                 fitting.
92358.........  Eye prosthesis        ......  X             0362      0.5865       36.05  ..........        7.21
                 service.
92371.........  Repair & adjust       ......  X             0362      0.5865       36.05  ..........        7.21
                 spectacles.
92499.........  Eye service or        ......  S             0230      0.7898       48.55       14.97        9.71
                 procedure.
92502.........  Ear and throat        ......  T             0251       2.452      150.72  ..........       30.14
                 examination.
92504.........  Ear microscopy        ......  N       ..........  ..........  ..........  ..........  ..........
                 examination.
92511.........  Nasopharyngoscopy...  ......  T             0071      0.7698       47.32       11.20        9.46
92512.........  Nasal function        ......  X             0363      0.8525       52.40       17.44       10.48
                 studies.
92516.........  Facial nerve          ......  X             0660      1.4461       88.89       28.06       17.78
                 function test.
92520.........  Laryngeal function    ......  X             0660      1.4461       88.89       28.06       17.78
                 studies.
92531.........  Spontaneous           ......  N       ..........  ..........  ..........  ..........  ..........
                 nystagmus study.
92532.........  Positional nystagmus  ......  N       ..........  ..........  ..........  ..........  ..........
                 test.
92533.........  Caloric vestibular    ......  N       ..........  ..........  ..........  ..........  ..........
                 test.
92534.........  Optokinetic           ......  N       ..........  ..........  ..........  ..........  ..........
                 nystagmus test.
92541.........  Spontaneous           ......  X             0363      0.8525       52.40       17.44       10.48
                 nystagmus test.
92542.........  Positional nystagmus  ......  X             0363      0.8525       52.40       17.44       10.48
                 test.
92543.........  Caloric vestibular    ......  X             0660      1.4461       88.89       28.06       17.78
                 test.
92544.........  Optokinetic           ......  X             0363      0.8525       52.40       17.44       10.48
                 nystagmus test.
92545.........  Oscillating tracking  ......  X             0363      0.8525       52.40       17.44       10.48
                 test.
92546.........  Sinusoidal            ......  X             0660      1.4461       88.89       28.06       17.78
                 rotational test.
92547.........  Supplemental          ......  X             0363      0.8525       52.40       17.44       10.48
                 electrical test.
92548.........  Posturography.......  ......  X             0660      1.4461       88.89       28.06       17.78
92552.........  Pure tone             ......  X             0364      0.4627       28.44        7.06        5.69
                 audiometry, air.
92553.........  Audiometry, air &     ......  X             0365      1.2419       76.34       18.52       15.27
                 bone.
92555.........  Speech threshold      ......  X             0364      0.4627       28.44        7.06        5.69
                 audiometry.
92556.........  Speech audiometry,    ......  X             0364      0.4627       28.44        7.06        5.69
                 complete.
92557.........  Comprehensive         ......  X             0365      1.2419       76.34       18.52       15.27
                 hearing test.
92561.........  Bekesy audiometry,    ......  X             0364      0.4627       28.44        7.06        5.69
                 diagnosis.
92562.........  Loudness balance      ......  X             0364      0.4627       28.44        7.06        5.69
                 test.
92563.........  Tone decay hearing    ......  X             0364      0.4627       28.44        7.06        5.69
                 test.
92564.........  Sisi hearing test...  ......  X             0364      0.4627       28.44        7.06        5.69
92565.........  Stenger test, pure    ......  X             0364      0.4627       28.44        7.06        5.69
                 tone.
92567.........  Tympanometry........  ......  X             0364      0.4627       28.44        7.06        5.69
92568.........  Acoustic refl         ......  X             0364      0.4627       28.44        7.06        5.69
                 threshold tst.
92569.........  Acoustic reflex       ......  X             0364      0.4627       28.44        7.06        5.69
                 decay test.
92571.........  Filtered speech       ......  X             0364      0.4627       28.44        7.06        5.69
                 hearing test.
92572.........  Staggered spondaic    ......  X             0366      1.8511      113.78       26.14       22.76
                 word test.
92573.........  Lombard test........   CH...  D       ..........  ..........  ..........  ..........  ..........
92575.........  Sensorineural acuity  ......  X             0364      0.4627       28.44        7.06        5.69
                 test.
92576.........  Synthetic sentence    ......  X             0364      0.4627       28.44        7.06        5.69
                 test.
92577.........  Stenger test, speech  ......  X             0366      1.8511      113.78       26.14       22.76
92579.........  Visual audiometry     ......  X             0365      1.2419       76.34       18.52       15.27
                 (vra).
92582.........  Conditioning play     ......  X             0365      1.2419       76.34       18.52       15.27
                 audiometry.
92583.........  Select picture        ......  X             0364      0.4627       28.44        7.06        5.69
                 audiometry.
92584.........  Electrocochleography  ......  X             0660      1.4461       88.89       28.06       17.78
92585.........  Auditor evoke         ......  S             0216      2.7199      167.19  ..........       33.44
                 potent, compre.
92586.........  Auditor evoke         ......  S             0218      1.1872       72.97  ..........       14.59
                 potent, limit.
92587.........  Evoked auditory test  ......  X             0363      0.8525       52.40       17.44       10.48
92588.........  Evoked auditory test  ......  X             0660      1.4461       88.89       28.06       17.78
92596.........  Ear protector         ......  X             0364      0.4627       28.44        7.06        5.69
                 evaluation.
92601.........  Cochlear implt f/up   ......  X             0366      1.8511      113.78       26.14       22.76
                 exam < 7.
92602.........  Reprogram cochlear    ......  X             0366      1.8511      113.78       26.14       22.76
                 implt < 7.
92603.........  Cochlear implt f/up   ......  X             0366      1.8511      113.78       26.14       22.76
                 exam 7 >.
92604.........  Reprogram cochlear    ......  X             0366      1.8511      113.78       26.14       22.76
                 implt 7 >.
92620.........  Auditory function,    ......  X             0365      1.2419       76.34       18.52       15.27
                 60 min.
92621.........  Auditory function, +  ......  N       ..........  ..........  ..........  ..........  ..........
                 15 min.
92625.........  Tinnitus assessment.  ......  X             0365      1.2419       76.34       18.52       15.27
92626.........  Eval aud rehab        ......  X             0365      1.2419       76.34       18.52       15.27
                 status.
92627.........  Eval aud status       ......  N       ..........  ..........  ..........  ..........  ..........
                 rehab add-on.
92640.........  Aud brainstem implt    NI...  X             0365      1.2419       76.34       18.52       15.27
                 programg.
92700.........  Ent procedure/        ......  X             0364      0.4627       28.44        7.06        5.69
                 service.
92950.........  Heart/lung            ......  S             0094      2.4233      148.96       46.29       29.79
                 resuscitation cpr.
92953.........  Temporary external    ......  S             0094      2.4233      148.96       46.29       29.79
                 pacing.
92960.........  Cardioversion         ......  S             0679      5.5233      339.51       95.30       67.90
                 electric, ext.

[[Page 68358]]

 
92961.........  Cardioversion,        ......  S             0679      5.5233      339.51       95.30       67.90
                 electric, int.
92973.........  Percut coronary       ......  T             0088     37.7391    2,319.75      655.22      463.95
                 thrombectomy.
92974.........  Cath place, cardio    ......  T             0103     16.2375      998.09      223.63      199.62
                 brachytx.
92977.........  Dissolve clot, heart  ......  T             0676      2.0726      127.40  ..........       25.48
                 vessel.
92978.........  Intravasc us, heart   ......  S             0670     32.2854    1,984.52      536.10      396.90
                 add-on.
92979.........  Intravasc us, heart   ......  S             0416     32.5472    2,000.61  ..........      400.12
                 add-on.
92980.........  Insert intracoronary  ......  T             0104     87.7183    5,391.87  ..........    1,078.37
                 stent.
92981.........  Insert intracoronary  ......  T             0104     87.7183    5,391.87  ..........    1,078.37
                 stent.
92982.........  Coronary artery       ......  T             0083     58.7904    3,613.73  ..........      722.75
                 dilation.
92984.........  Coronary artery       ......  T             0083     58.7904    3,613.73  ..........      722.75
                 dilation.
92986.........  Revision of aortic    ......  T             0083     58.7904    3,613.73  ..........      722.75
                 valve.
92987.........  Revision of mitral    ......  T             0083     58.7904    3,613.73  ..........      722.75
                 valve.
92990.........  Revision of           ......  T             0083     58.7904    3,613.73  ..........      722.75
                 pulmonary valve.
92995.........  Coronary atherectomy  ......  T             0082     72.1982    4,437.88      954.62      887.58
92996.........  Coronary atherectomy  ......  T             0082     72.1982    4,437.88      954.62      887.58
                 add-on.
92997.........  Pul art balloon       ......  T             0081      42.936    2,639.19  ..........      527.84
                 repr, percut.
92998.........  Pul art balloon       ......  T             0081      42.936    2,639.19  ..........      527.84
                 repr, percut.
93005.........  Electrocardiogram,    ......  S             0099      0.3789       23.29  ..........        4.66
                 tracing.
93012.........  Transmission of ecg.  ......  N       ..........  ..........  ..........  ..........  ..........
93017.........  Cardiovascular        ......  X             0100      2.5336      155.74       41.44       31.15
                 stress test.
93024.........  Cardiac drug stress   ......  X             0100      2.5336      155.74       41.44       31.15
                 test.
93025.........  Microvolt t-wave      ......  X             0100      2.5336      155.74       41.44       31.15
                 assess.
93041.........  Rhythm ECG, tracing.  ......  S             0099      0.3789       23.29  ..........        4.66
93225.........  ECG monitor/record,   ......  X             0097      1.0225       62.85       23.79       12.57
                 24 hrs.
93226.........  ECG monitor/report,   ......  X             0097      1.0225       62.85       23.79       12.57
                 24 hrs.
93231.........  Ecg monitor/record,   ......  X             0097      1.0225       62.85       23.79       12.57
                 24 hrs.
93232.........  ECG monitor/report,   ......  X             0097      1.0225       62.85       23.79       12.57
                 24 hrs.
93236.........  ECG monitor/report,   ......  X             0097      1.0225       62.85       23.79       12.57
                 24 hrs.
93270.........  ECG recording.......  ......  X             0097      1.0225       62.85       23.79       12.57
93271.........  Ecg/monitoring and    ......  X             0097      1.0225       62.85       23.79       12.57
                 analysis.
93278.........  ECG/signal-averaged.  ......  S             0099      0.3789       23.29  ..........        4.66
93303.........  Echo transthoracic..  ......  S             0269      3.2154      197.64       75.60       39.53
93304.........  Echo transthoracic..  ......  S             0697      1.5973       98.18       35.99       19.64
93307.........  Echo exam of heart..  ......  S             0269      3.2154      197.64       75.60       39.53
93308.........  Echo exam of heart..  ......  S             0697      1.5973       98.18       35.99       19.64
93312.........  Echo transesophageal  ......  S             0270      6.2505      384.21      141.32       76.84
93313.........  Echo transesophageal  ......  S             0270      6.2505      384.21      141.32       76.84
93314.........  Echo transesophageal  ......  N       ..........  ..........  ..........  ..........  ..........
93315.........  Echo transesophageal  ......  S             0270      6.2505      384.21      141.32       76.84
93316.........  Echo transesophageal  ......  S             0270      6.2505      384.21      141.32       76.84
93317.........  Echo transesophageal  ......  N       ..........  ..........  ..........  ..........  ..........
93318.........  Echo transesophageal  ......  S             0270      6.2505      384.21      141.32       76.84
                 intraop.
93320.........  Doppler echo exam,     CH...  S             0697      1.5973       98.18       35.99       19.64
                 heart.
93321.........  Doppler echo exam,    ......  S             0697      1.5973       98.18       35.99       19.64
                 heart.
93325.........  Doppler color flow    ......  S             0697      1.5973       98.18       35.99       19.64
                 add-on.
93350.........  Echo transthoracic..  ......  S             0269      3.2154      197.64       75.60       39.53
93501.........  Right heart           ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93503.........  Insert/place heart    ......  T             0103     16.2375      998.09      223.63      199.62
                 catheter.
93505.........  Biopsy of heart       ......  T             0103     16.2375      998.09      223.63      199.62
                 lining.
93508.........  Cath placement,       ......  T             0080     37.0615    2,278.10      838.92      455.62
                 angiography.
93510.........  Left heart            ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93511.........  Left heart            ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93514.........  Left heart            ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93524.........  Left heart            ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93526.........  Rt & lT heart         ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheters.
93527.........  Rt & lT heart         ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheters.
93528.........  Rt & lT heart         ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheters.
93529.........  Rt, lt heart          ......  T             0080     37.0615    2,278.10      838.92      455.62
                 catheterization.
93530.........  Rt heart cath,        ......  T             0080     37.0615    2,278.10      838.92      455.62
                 congenital.
93531.........  R& l heart cath,      ......  T             0080     37.0615    2,278.10      838.92      455.62
                 congenital.
93532.........  R& l heart cath,      ......  T             0080     37.0615    2,278.10      838.92      455.62
                 congenital.
93533.........  R& l heart cath,      ......  T             0080     37.0615    2,278.10      838.92      455.62
                 congenital.
93539.........  Injection, cardiac    ......  N       ..........  ..........  ..........  ..........  ..........
                 cath.
93540.........  Injection, cardiac    ......  N       ..........  ..........  ..........  ..........  ..........
                 cath.
93541.........  Injection for lung    ......  N       ..........  ..........  ..........  ..........  ..........
                 angiogram.
93542.........  Injection for heart   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-rays.
93543.........  Injection for heart   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-rays.
93544.........  Injection for         ......  N       ..........  ..........  ..........  ..........  ..........
                 aortography.
93545.........  Inject for coronary   ......  N       ..........  ..........  ..........  ..........  ..........
                 x-rays.
93555.........  Imaging, cardiac      ......  N       ..........  ..........  ..........  ..........  ..........
                 cath.

[[Page 68359]]

 
93556.........  Imaging, cardiac      ......  N       ..........  ..........  ..........  ..........  ..........
                 cath.
93561.........  Cardiac output        ......  N       ..........  ..........  ..........  ..........  ..........
                 measurement.
93562.........  Cardiac output        ......  N       ..........  ..........  ..........  ..........  ..........
                 measurement.
93571.........  Heart flow reserve    ......  S             0670     32.2854    1,984.52      536.10      396.90
                 measure.
93572.........  Heart flow reserve    ......  S             0416     32.5472    2,000.61  ..........      400.12
                 measure.
93580.........  Transcath closure of  ......  T             0434     88.0728    5,413.66  ..........    1,082.73
                 asd.
93581.........  Transcath closure of  ......  T             0434     88.0728    5,413.66  ..........    1,082.73
                 vsd.
93600.........  Bundle of His         ......  T             0087     32.8988    2,022.22  ..........      404.44
                 recording.
93602.........  Intra-atrial          ......  T             0087     32.8988    2,022.22  ..........      404.44
                 recording.
93603.........  Right ventricular     ......  T             0087     32.8988    2,022.22  ..........      404.44
                 recording.
93609.........  Map tachycardia, add- ......  T             0087     32.8988    2,022.22  ..........      404.44
                 on.
93610.........  Intra-atrial pacing.  ......  T             0087     32.8988    2,022.22  ..........      404.44
93612.........  Intraventricular      ......  T             0087     32.8988    2,022.22  ..........      404.44
                 pacing.
93613.........  Electrophys map 3d,   ......  T             0087     32.8988    2,022.22  ..........      404.44
                 add-on.
93615.........  Esophageal recording  ......  T             0087     32.8988    2,022.22  ..........      404.44
93616.........  Esophageal recording  ......  T             0087     32.8988    2,022.22  ..........      404.44
93618.........  Heart rhythm pacing.  ......  T             0087     32.8988    2,022.22  ..........      404.44
93619.........  Electrophysiology     ......  T             0085     34.2808    2,107.17      426.25      421.43
                 evaluation.
93620.........  Electrophysiology     ......  T             0085     34.2808    2,107.17      426.25      421.43
                 evaluation.
93621.........  Electrophysiology     ......  T             0085     34.2808    2,107.17      426.25      421.43
                 evaluation.
93622.........  Electrophysiology     ......  T             0085     34.2808    2,107.17      426.25      421.43
                 evaluation.
93623.........  Stimulation, pacing   ......  T             0087     32.8988    2,022.22  ..........      404.44
                 heart.
93624.........  Electrophysiologic    ......  T             0085     34.2808    2,107.17      426.25      421.43
                 study.
93631.........  Heart pacing,         ......  T             0087     32.8988    2,022.22  ..........      404.44
                 mapping.
93640.........  Evaluation heart       CH...  N       ..........  ..........  ..........  ..........  ..........
                 device.
93641.........  Electrophysiology      CH...  N       ..........  ..........  ..........  ..........  ..........
                 evaluation.
93642.........  Electrophysiology     ......  S             0084      9.8924      608.07  ..........      121.61
                 evaluation.
93650.........  Ablate heart          ......  T             0086     47.4931    2,919.31      812.36      583.86
                 dysrhythm focus.
93651.........  Ablate heart          ......  T             0086     47.4931    2,919.31      812.36      583.86
                 dysrhythm focus.
93652.........  Ablate heart          ......  T             0086     47.4931    2,919.31      812.36      583.86
                 dysrhythm focus.
93660.........  Tilt table            ......  S             0101      4.2769      262.89      100.24       52.58
                 evaluation.
93662.........  Intracardiac ecg      ......  S             0670     32.2854    1,984.52      536.10      396.90
                 (ice).
93701.........  Bioimpedance,         ......  S             0099      0.3789       23.29  ..........        4.66
                 thoracic.
93721.........  Plethysmography       ......  X             0368      0.9454       58.11       22.77       11.62
                 tracing.
93724.........  Analyze pacemaker     ......  S             0690      0.3613       22.21        8.67        4.44
                 system.
93727.........  Analyze ilr system..  ......  S             0690      0.3613       22.21        8.67        4.44
93731.........  Analyze pacemaker     ......  S             0690      0.3613       22.21        8.67        4.44
                 system.
93732.........  Analyze pacemaker     ......  S             0690      0.3613       22.21        8.67        4.44
                 system.
93733.........  Telephone analy,      ......  S             0690      0.3613       22.21        8.67        4.44
                 pacemaker.
93734.........  Analyze pacemaker     ......  S             0690      0.3613       22.21        8.67        4.44
                 system.
93735.........  Analyze pacemaker     ......  S             0690      0.3613       22.21        8.67        4.44
                 system.
93736.........  Telephonic analy,     ......  S             0690      0.3613       22.21        8.67        4.44
                 pacemaker.
93740.........  Temperature gradient  ......  X             0368      0.9454       58.11       22.77       11.62
                 studies.
93741.........  Analyze ht pace       ......  S             0689      0.6003       36.90  ..........        7.38
                 device sngl.
93742.........  Analyze ht pace       ......  S             0689      0.6003       36.90  ..........        7.38
                 device sngl.
93743.........  Analyze ht pace       ......  S             0689      0.6003       36.90  ..........        7.38
                 device dual.
93744.........  Analyze ht pace       ......  S             0689      0.6003       36.90  ..........        7.38
                 device dual.
93745.........  Set-up cardiovert-    ......  S             0689      0.6003       36.90  ..........        7.38
                 defibrill.
93770.........  Measure venous        ......  N       ..........  ..........  ..........  ..........  ..........
                 pressure.
93786.........  Ambulatory BP         ......  X             0097      1.0225       62.85       23.79       12.57
                 recording.
93788.........  Ambulatory BP         ......  X             0097      1.0225       62.85       23.79       12.57
                 analysis.
93797.........  Cardiac rehab.......  ......  S             0095      0.5748       35.33       13.86        7.07
93798.........  Cardiac rehab/        ......  S             0095      0.5748       35.33       13.86        7.07
                 monitor.
93799.........  Cardiovascular         CH...  X             0097      1.0225       62.85       23.79       12.57
                 procedure.
93875.........  Extracranial study..  ......  S             0096      1.5303       94.06       37.62       18.81
93880.........  Extracranial study..  ......  S             0267      2.4606      151.25       60.50       30.25
93882.........  Extracranial study..  ......  S             0267      2.4606      151.25       60.50       30.25
93886.........  Intracranial study..  ......  S             0267      2.4606      151.25       60.50       30.25
93888.........  Intracranial study..   CH...  S             0265      0.9923       60.99       23.63       12.20
93890.........  Tcd, vasoreactivity   ......  S             0266      1.5607       95.93       37.80       19.19
                 study.
93892.........  Tcd, emboli detect w/ ......  S             0266      1.5607       95.93       37.80       19.19
                 o inj.
93893.........  Tcd, emboli detect w/ ......  S             0266      1.5607       95.93       37.80       19.19
                 inj.
93922.........  Extremity study.....  ......  S             0096      1.5303       94.06       37.62       18.81
93923.........  Extremity study.....  ......  S             0096      1.5303       94.06       37.62       18.81
93924.........  Extremity study.....  ......  S             0096      1.5303       94.06       37.62       18.81
93925.........  Lower extremity       ......  S             0267      2.4606      151.25       60.50       30.25
                 study.
93926.........  Lower extremity       ......  S             0266      1.5607       95.93       37.80       19.19
                 study.
93930.........  Upper extremity       ......  S             0267      2.4606      151.25       60.50       30.25
                 study.
93931.........  Upper extremity       ......  S             0266      1.5607       95.93       37.80       19.19
                 study.
93965.........  Extremity study.....  ......  S             0096      1.5303       94.06       37.62       18.81

[[Page 68360]]

 
93970.........  Extremity study.....  ......  S             0267      2.4606      151.25       60.50       30.25
93971.........  Extremity study.....  ......  S             0266      1.5607       95.93       37.80       19.19
93975.........  Vascular study......  ......  S             0267      2.4606      151.25       60.50       30.25
93976.........  Vascular study......  ......  S             0267      2.4606      151.25       60.50       30.25
93978.........  Vascular study......  ......  S             0266      1.5607       95.93       37.80       19.19
93979.........  Vascular study......  ......  S             0266      1.5607       95.93       37.80       19.19
93980.........  Penile vascular       ......  S             0267      2.4606      151.25       60.50       30.25
                 study.
93981.........  Penile vascular       ......  S             0266      1.5607       95.93       37.80       19.19
                 study.
93990.........  Doppler flow testing  ......  S             0266      1.5607       95.93       37.80       19.19
94002.........  Vent mgmt inpat,       NI...  S             0079      2.6116      160.53  ..........       32.11
                 init day.
94003.........  Vent mgmt inpat,       NI...  S             0079      2.6116      160.53  ..........       32.11
                 subq day.
94004.........  Vent mgmt nf per day   NI...  B       ..........  ..........  ..........  ..........  ..........
94005.........  Home vent mgmt         NI...  E       ..........  ..........  ..........  ..........  ..........
                 supervision.
94010.........  Breathing capacity    ......  X             0368      0.9454       58.11       22.77       11.62
                 test.
94014.........  Patient recorded      ......  X             0367      0.6277       38.58       14.68        7.72
                 spirometry.
94015.........  Patient recorded      ......  X             0367      0.6277       38.58       14.68        7.72
                 spirometry.
94060.........  Evaluation of         ......  X             0368      0.9454       58.11       22.77       11.62
                 wheezing.
94070.........  Evaluation of         ......  X             0369      2.7669      170.08       44.18       34.02
                 wheezing.
94150.........  Vital capacity test.  ......  X             0367      0.6277       38.58       14.68        7.72
94200.........  Lung function test    ......  X             0367      0.6277       38.58       14.68        7.72
                 (MBC/MVV).
94240.........  Residual lung         ......  X             0368      0.9454       58.11       22.77       11.62
                 capacity.
94250.........  Expired gas           ......  X             0367      0.6277       38.58       14.68        7.72
                 collection.
94260.........  Thoracic gas volume.   CH...  X             0368      0.9454       58.11       22.77       11.62
94350.........  Lung nitrogen          CH...  X             0368      0.9454       58.11       22.77       11.62
                 washout curve.
94360.........  Measure airflow       ......  X             0367      0.6277       38.58       14.68        7.72
                 resistance.
94370.........  Breath airway         ......  X             0367      0.6277       38.58       14.68        7.72
                 closing volume.
94375.........  Respiratory flow      ......  X             0367      0.6277       38.58       14.68        7.72
                 volume loop.
94400.........  CO2 breathing         ......  X             0367      0.6277       38.58       14.68        7.72
                 response curve.
94450.........  Hypoxia response      ......  X             0368      0.9454       58.11       22.77       11.62
                 curve.
94452.........  Hast w/report.......  ......  X             0368      0.9454       58.11       22.77       11.62
94453.........  Hast w/oxygen          CH...  X             0367      0.6277       38.58       14.68        7.72
                 titrate.
94610.........  Surfactant admin       NI...  S             0077      0.3527       21.68        7.74        4.34
                 thru tube.
94620.........  Pulmonary stress      ......  X             0368      0.9454       58.11       22.77       11.62
                 test/simple.
94621.........  Pulm stress test/     ......  X             0369      2.7669      170.08       44.18       34.02
                 complex.
94640.........  Airway inhalation     ......  S             0077      0.3527       21.68        7.74        4.34
                 treatment.
94642.........  Aerosol inhalation    ......  S             0078      1.1206       68.88       14.55       13.78
                 treatment.
94644.........  Cbt, 1st hour.......   NI...  S             0078      1.1206       68.88       14.55       13.78
94645.........  Cbt, each addl hour.   NI...  S             0078      1.1206       68.88       14.55       13.78
94656.........  Initial ventilator     CH...  D       ..........  ..........  ..........  ..........  ..........
                 mgmt.
94657.........  Continued ventilator   CH...  D       ..........  ..........  ..........  ..........  ..........
                 mgmt.
94660.........  Pos airway pressure,  ......  S             0068      1.5353       94.37       29.48       18.87
                 CPAP.
94662.........  Neg press             ......  S             0079      2.6116      160.53  ..........       32.11
                 ventilation, cnp.
94664.........  Evaluate pt use of    ......  S             0077      0.3527       21.68        7.74        4.34
                 inhaler.
94667.........  Chest wall            ......  S             0077      0.3527       21.68        7.74        4.34
                 manipulation.
94668.........  Chest wall            ......  S             0077      0.3527       21.68        7.74        4.34
                 manipulation.
94680.........  Exhaled air           ......  X             0367      0.6277       38.58       14.68        7.72
                 analysis, o2.
94681.........  Exhaled air           ......  X             0368      0.9454       58.11       22.77       11.62
                 analysis, o2/co2.
94690.........  Exhaled air analysis   CH...  X             0367      0.6277       38.58       14.68        7.72
94720.........  Monoxide diffusing    ......  X             0368      0.9454       58.11       22.77       11.62
                 capacity.
94725.........  Membrane diffusion    ......  X             0368      0.9454       58.11       22.77       11.62
                 capacity.
94750.........  Pulmonary compliance   CH...  X             0367      0.6277       38.58       14.68        7.72
                 study.
94760.........  Measure blood oxygen  ......  N       ..........  ..........  ..........  ..........  ..........
                 level.
94761.........  Measure blood oxygen  ......  N       ..........  ..........  ..........  ..........  ..........
                 level.
94762.........  Measure blood oxygen   CH...  Q             0443      1.0409       63.98       25.59       12.80
                 level.
94770.........  Exhaled carbon        ......  X             0367      0.6277       38.58       14.68        7.72
                 dioxide test.
94772.........  Breath recording,     ......  X             0369      2.7669      170.08       44.18       34.02
                 infant.
94774.........  Ped home apnea rec,    NI...  B       ..........  ..........  ..........  ..........  ..........
                 compl.
94775.........  Ped home apnea rec,    NI...  X             0097      1.0225       62.85       23.79       12.57
                 hk-up.
94776.........  Ped home apnea rec,    NI...  X             0097      1.0225       62.85       23.79       12.57
                 downld.
94777.........  Ped home apnea rec,    NI...  B       ..........  ..........  ..........  ..........  ..........
                 report.
94799.........  Pulmonary service/    ......  X             0367      0.6277       38.58       14.68        7.72
                 procedure.
95004.........  Percut allergy skin   ......  X             0381      0.2688       16.52  ..........        3.30
                 tests.
95010.........  Percut allergy        ......  X             0381      0.2688       16.52  ..........        3.30
                 titrate test.
95012.........  Exhaled nitric oxide   NI...  X             0367      0.6277       38.58       14.68        7.72
                 meas.
95015.........  Id allergy titrate-   ......  X             0381      0.2688       16.52  ..........        3.30
                 drug/bug.
95024.........  Id allergy test,      ......  X             0381      0.2688       16.52  ..........        3.30
                 drug/bug.
95027.........  Id allergy titrate-   ......  X             0381      0.2688       16.52  ..........        3.30
                 airborne.
95028.........  Id allergy test-      ......  X             0381      0.2688       16.52  ..........        3.30
                 delayed type.
95044.........  Allergy patch tests.  ......  X             0381      0.2688       16.52  ..........        3.30
95052.........  Photo patch test....  ......  X             0381      0.2688       16.52  ..........        3.30

[[Page 68361]]

 
95056.........  Photosensitivity      ......  X             0370       1.027       63.13  ..........       12.63
                 tests.
95060.........  Eye allergy tests...  ......  X             0370       1.027       63.13  ..........       12.63
95065.........  Nose allergy test...  ......  X             0381      0.2688       16.52  ..........        3.30
95070.........  Bronchial allergy     ......  X             0369      2.7669      170.08       44.18       34.02
                 tests.
95071.........  Bronchial allergy     ......  X             0369      2.7669      170.08       44.18       34.02
                 tests.
95075.........  Ingestion challenge   ......  X             0361      3.8887      239.03       83.23       47.81
                 test.
95078.........  Provocative testing.   CH...  D       ..........  ..........  ..........  ..........  ..........
95115.........  Immunotherapy, one     CH...  S             0436      0.1809       11.12  ..........        2.22
                 injection.
95117.........  Immunotherapy          CH...  S             0437      0.3945       24.25  ..........        4.85
                 injections.
95144.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95145.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95146.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95147.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95148.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95149.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95165.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95170.........  Antigen therapy        CH...  S             0437      0.3945       24.25  ..........        4.85
                 services.
95180.........  Rapid                 ......  X             0370       1.027       63.13  ..........       12.63
                 desensitization.
95199.........  Allergy immunology     CH...  X             0381      0.2688       16.52  ..........        3.30
                 services.
95250.........  Glucose monitoring,   ......  X             0421       1.627      100.01  ..........       20.00
                 cont.
95805.........  Multiple sleep        ......  S             0209     11.2463      691.29      268.73      138.26
                 latency test.
95806.........  Sleep study,          ......  S             0213      2.2755      139.87       53.58       27.97
                 unattended.
95807.........  Sleep study,          ......  S             0209     11.2463      691.29      268.73      138.26
                 attended.
95808.........  Polysomnography, 1-3  ......  S             0209     11.2463      691.29      268.73      138.26
95810.........  Polysomnography, 4    ......  S             0209     11.2463      691.29      268.73      138.26
                 or more.
95811.........  Polysomnography w/    ......  S             0209     11.2463      691.29      268.73      138.26
                 cpap.
95812.........  Eeg, 41-60 minutes..  ......  S             0213      2.2755      139.87       53.58       27.97
95813.........  Eeg, over 1 hour....  ......  S             0213      2.2755      139.87       53.58       27.97
95816.........  Eeg, awake and        ......  S             0213      2.2755      139.87       53.58       27.97
                 drowsy.
95819.........  Eeg, awake and        ......  S             0213      2.2755      139.87       53.58       27.97
                 asleep.
95822.........  Eeg, coma or sleep    ......  S             0213      2.2755      139.87       53.58       27.97
                 only.
95824.........  Eeg, cerebral death   ......  S             0214      1.1968       73.56       28.24       14.71
                 only.
95827.........  Eeg, all night        ......  S             0213      2.2755      139.87       53.58       27.97
                 recording.
95829.........  Surgery               ......  S             0214      1.1968       73.56       28.24       14.71
                 electrocorticogram.
95857.........  Tensilon test.......  ......  S             0218      1.1872       72.97  ..........       14.59
95860.........  Muscle test, one      ......  S             0218      1.1872       72.97  ..........       14.59
                 limb.
95861.........  Muscle test, 2 limbs  ......  S             0218      1.1872       72.97  ..........       14.59
95863.........  Muscle test, 3 limbs  ......  S             0218      1.1872       72.97  ..........       14.59
95864.........  Muscle test, 4 limbs  ......  S             0218      1.1872       72.97  ..........       14.59
95865.........  Muscle test, larynx.  ......  S             0218      1.1872       72.97  ..........       14.59
95866.........  Muscle test,          ......  S             0218      1.1872       72.97  ..........       14.59
                 hemidiaphragm.
95867.........  Muscle test cran      ......  S             0218      1.1872       72.97  ..........       14.59
                 nerv unilat.
95868.........  Muscle test cran      ......  S             0218      1.1872       72.97  ..........       14.59
                 nerve bilat.
95869.........  Muscle test, thor     ......  S             0215      0.5741       35.29  ..........        7.06
                 paraspinal.
95870.........  Muscle test,          ......  S             0215      0.5741       35.29  ..........        7.06
                 nonparaspinal.
95872.........  Muscle test, one      ......  S             0218      1.1872       72.97  ..........       14.59
                 fiber.
95873.........  Guide nerv destr,     ......  S             0215      0.5741       35.29  ..........        7.06
                 elec stim.
95874.........  Guide nerv destr,     ......  S             0215      0.5741       35.29  ..........        7.06
                 needle emg.
95875.........  Limb exercise test..  ......  S             0215      0.5741       35.29  ..........        7.06
95900.........  Motor nerve           ......  S             0215      0.5741       35.29  ..........        7.06
                 conduction test.
95903.........  Motor nerve           ......  S             0215      0.5741       35.29  ..........        7.06
                 conduction test.
95904.........  Sense nerve           ......  S             0215      0.5741       35.29  ..........        7.06
                 conduction test.
95920.........  Intraop nerve test    ......  S             0216      2.7199      167.19  ..........       33.44
                 add-on.
95921.........  Autonomic nerv         CH...  S             0215      0.5741       35.29  ..........        7.06
                 function test.
95922.........  Autonomic nerv         CH...  S             0215      0.5741       35.29  ..........        7.06
                 function test.
95923.........  Autonomic nerv         CH...  S             0215      0.5741       35.29  ..........        7.06
                 function test.
95925.........  Somatosensory         ......  S             0216      2.7199      167.19  ..........       33.44
                 testing.
95926.........  Somatosensory         ......  S             0216      2.7199      167.19  ..........       33.44
                 testing.
95927.........  Somatosensory         ......  S             0216      2.7199      167.19  ..........       33.44
                 testing.
95928.........  Cmotor evoked, uppr   ......  S             0218      1.1872       72.97  ..........       14.59
                 limbs.
95929.........  Cmotor evoked, lwr    ......  S             0218      1.1872       72.97  ..........       14.59
                 limbs.
95930.........  Visual evoked         ......  S             0216      2.7199      167.19  ..........       33.44
                 potential test.
95933.........  Blink reflex test...  ......  S             0215      0.5741       35.29  ..........        7.06
95934.........  H-reflex test.......  ......  S             0215      0.5741       35.29  ..........        7.06
95936.........  H-reflex test.......  ......  S             0215      0.5741       35.29  ..........        7.06
95937.........  Neuromuscular          CH...  S             0215      0.5741       35.29  ..........        7.06
                 junction test.
95950.........  Ambulatory eeg        ......  S             0209     11.2463      691.29      268.73      138.26
                 monitoring.
95951.........  EEG monitoring/       ......  S             0209     11.2463      691.29      268.73      138.26
                 videorecord.
95953.........  EEG monitoring/       ......  S             0209     11.2463      691.29      268.73      138.26
                 computer.
95954.........  EEG monitoring/       ......  S             0214      1.1968       73.56       28.24       14.71
                 giving drugs.

[[Page 68362]]

 
95955.........  EEG during surgery..  ......  S             0213      2.2755      139.87       53.58       27.97
95956.........  Eeg monitoring,       ......  S             0209     11.2463      691.29      268.73      138.26
                 cable/radio.
95957.........  EEG digital analysis  ......  S             0214      1.1968       73.56       28.24       14.71
95958.........  EEG monitoring/       ......  S             0213      2.2755      139.87       53.58       27.97
                 function test.
95961.........  Electrode             ......  S             0216      2.7199      167.19  ..........       33.44
                 stimulation, brain.
95962.........  Electrode stim,       ......  S             0216      2.7199      167.19  ..........       33.44
                 brain add-on.
95965.........  Meg, spontaneous....   CH...  S             0038     53.5161    3,289.53  ..........      657.91
95966.........  Meg, evoked, single.   CH...  S             0209     11.2463      691.29      268.73      138.26
95967.........  Meg, evoked, each      CH...  S             0209     11.2463      691.29      268.73      138.26
                 add[AElig]l.
95970.........  Analyze neurostim,    ......  S             0218      1.1872       72.97  ..........       14.59
                 no prog.
95971.........  Analyze neurostim,    ......  S             0692      1.9323      118.77       30.16       23.75
                 simple.
95972.........  Analyze neurostim,    ......  S             0692      1.9323      118.77       30.16       23.75
                 complex.
95973.........  Analyze neurostim,     CH...  S             0663      1.1067       68.03       17.45       13.61
                 complex.
95974.........  Cranial neurostim,    ......  S             0692      1.9323      118.77       30.16       23.75
                 complex.
95975.........  Cranial neurostim,    ......  S             0692      1.9323      118.77       30.16       23.75
                 complex.
95978.........  Analyze neurostim     ......  S             0692      1.9323      118.77       30.16       23.75
                 brain/1h.
95979.........  Analyz neurostim       CH...  S             0663      1.1067       68.03       17.45       13.61
                 brain addon.
95990.........  Spin/brain pump       ......  T             0125      2.2041      135.48  ..........       27.10
                 refil & main.
95991.........  Spin/brain pump       ......  T             0125      2.2041      135.48  ..........       27.10
                 refil & main.
95999.........  Neurological          ......  S             0215      0.5741       35.29  ..........        7.06
                 procedure.
96000.........  Motion analysis,      ......  S             0216      2.7199      167.19  ..........       33.44
                 video/3d.
96001.........  Motion test w/ft      ......  S             0216      2.7199      167.19  ..........       33.44
                 press meas.
96002.........  Dynamic surface emg.  ......  S             0218      1.1872       72.97  ..........       14.59
96003.........  Dynamic fine wire     ......  S             0215      0.5741       35.29  ..........        7.06
                 emg.
96020.........  Functional brain       NI...  X             0373      1.7682      108.69  ..........       21.74
                 mapping.
96040.........  Genetic counseling,    NI...  E       ..........  ..........  ..........  ..........  ..........
                 30 min.
96101.........  Psycho testing by     ......  X             0373      1.7682      108.69  ..........       21.74
                 psych/phys.
96102.........  Psycho testing by     ......  X             0382       2.846      174.94       69.97       34.99
                 technician.
96103.........  Psycho testing admin  ......  X             0373      1.7682      108.69  ..........       21.74
                 by comp.
96110.........  Developmental test,   ......  X             0373      1.7682      108.69  ..........       21.74
                 lim.
96111.........  Developmental test,   ......  X             0373      1.7682      108.69  ..........       21.74
                 extend.
96116.........  Neurobehavioral       ......  X             0373      1.7682      108.69  ..........       21.74
                 status exam.
96118.........  Neuropsych tst by     ......  X             0373      1.7682      108.69  ..........       21.74
                 psych/phys.
96119.........  Neuropsych testing    ......  X             0382       2.846      174.94       69.97       34.99
                 by tec.
96120.........  Neuropsych tst admin  ......  X             0373      1.7682      108.69  ..........       21.74
                 w/comp.
96150.........  Assess hlth/behave,   ......  S             0432      0.6072       37.32  ..........        7.46
                 init.
96151.........  Assess hlth/behave,   ......  S             0432      0.6072       37.32  ..........        7.46
                 subseq.
96152.........  Intervene hlth/       ......  S             0432      0.6072       37.32  ..........        7.46
                 behave, indiv.
96153.........  Intervene hlth/       ......  S             0432      0.6072       37.32  ..........        7.46
                 behave, group.
96154.........  Interv hlth/behav,    ......  S             0432      0.6072       37.32  ..........        7.46
                 fam w/pt.
96401.........  Chemo, anti-neopl,     CH...  S             0438      0.7942       48.82  ..........        9.76
                 sq/im.
96402.........  Chemo hormon           CH...  S             0438      0.7942       48.82  ..........        9.76
                 antineopl sq/im.
96405.........  Chemo intralesional,   CH...  S             0438      0.7942       48.82  ..........        9.76
                 up to 7.
96406.........  Chemo intralesional    CH...  S             0438      0.7942       48.82  ..........        9.76
                 over 7.
96409.........  Chemo, iv push, sngl   CH...  S             0439      1.5848       97.41  ..........       19.48
                 drug.
96411.........  Chemo, iv push, addl   CH...  S             0439      1.5848       97.41  ..........       19.48
                 drug.
96413.........  Chemo, iv infusion,    CH...  S             0441      2.4851      152.75  ..........       30.55
                 1 hr.
96415.........  Chemo, iv infusion,    CH...  S             0438      0.7942       48.82  ..........        9.76
                 addl hr.
96416.........  Chemo prolong infuse   CH...  S             0441      2.4851      152.75  ..........       30.55
                 w/pump.
96417.........  Chemo iv infus each    CH...  S             0438      0.7942       48.82  ..........        9.76
                 addl seq.
96420.........  Chemo, ia, push        CH...  S             0439      1.5848       97.41  ..........       19.48
                 tecnique.
96422.........  Chemo ia infusion up   CH...  S             0441      2.4851      152.75  ..........       30.55
                 to 1 hr.
96423.........  Chemo ia infuse each   CH...  S             0438      0.7942       48.82  ..........        9.76
                 addl hr.
96425.........  Chemotherapy,infusio   CH...  S             0441      2.4851      152.75  ..........       30.55
                 n method.
96440.........  Chemotherapy,          CH...  S             0441      2.4851      152.75  ..........       30.55
                 intracavitary.
96445.........  Chemotherapy,          CH...  S             0441      2.4851      152.75  ..........       30.55
                 intracavitary.
96450.........  Chemotherapy, into     CH...  S             0441      2.4851      152.75  ..........       30.55
                 CNS.
96521.........  Refill/maint,          CH...  S             0440       1.809      111.20  ..........       22.24
                 portable pump.
96522.........  Refill/maint pump/     CH...  S             0440       1.809      111.20  ..........       22.24
                 resvr syst.
96523.........  Irrig drug delivery    CH...  Q             0624      0.5145       31.63       12.65        6.33
                 device.
96542.........  Chemotherapy           CH...  S             0438      0.7942       48.82  ..........        9.76
                 injection.
96549.........  Chemotherapy,          CH...  S             0436      0.1809       11.12  ..........        2.22
                 unspecified.
96567.........  Photodynamic tx,      ......  T             0016      2.6749      164.42  ..........       32.88
                 skin.
96570.........  Photodynamic tx, 30   ......  T             0015      1.6241       99.83       20.13       19.97
                 min.
96571.........  Photodynamic tx,      ......  T             0015      1.6241       99.83       20.13       19.97
                 addl 15 min.
96900.........  Ultraviolet light     ......  S             0001      0.4914       30.21        7.00        6.04
                 therapy.
96902.........  Trichogram..........  ......  N       ..........  ..........  ..........  ..........  ..........
96904.........  Whole body             NI...  N       ..........  ..........  ..........  ..........  ..........
                 photography.
96910.........  Photochemotherapy     ......  S             0001      0.4914       30.21        7.00        6.04
                 with UV-B.
96912.........  Photochemotherapy     ......  S             0001      0.4914       30.21        7.00        6.04
                 with UV-A.

[[Page 68363]]

 
96913.........  Photochemotherapy,    ......  S             0683      2.6734      164.33  ..........       32.87
                 UV-A or B.
96920.........  Laser tx, skin < 250  ......  T             0013      1.0918       67.11  ..........       13.42
                 sq cm.
96921.........  Laser tx, skin 250-   ......  T             0013      1.0918       67.11  ..........       13.42
                 500 sq cm.
96922.........  Laser tx, skin > 500  ......  T             0013      1.0918       67.11  ..........       13.42
                 sq cm.
96999.........  Dermatological        ......  T             0010       0.476       29.26        8.02        5.85
                 procedure.
97597.........  Active wound care/20  ......  T             0012      0.8432       51.83       11.18       10.37
                 cm or <.
97598.........  Active wound care >   ......  T             0013      1.0918       67.11  ..........       13.42
                 20 cm.
97602.........  Wound(s) care non-    ......  X             0340      0.6102       37.51  ..........        7.50
                 selective.
97605.........  Neg press wound tx,   ......  T             0012      0.8432       51.83       11.18       10.37
                 < 50 cm.
97606.........  Neg press wound tx,   ......  T             0013      1.0918       67.11  ..........       13.42
                 > 50 cm.
98925.........  Osteopathic           ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98926.........  Osteopathic           ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98927.........  Osteopathic           ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98928.........  Osteopathic           ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98929.........  Osteopathic           ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98940.........  Chiropractic          ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98941.........  Chiropractic          ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
98942.........  Chiropractic          ......  S             0060      0.4657       28.63  ..........        5.73
                 manipulation.
99078.........  Group health          ......  N       ..........  ..........  ..........  ..........  ..........
                 education.
99091.........  Collect/review data   ......  N       ..........  ..........  ..........  ..........  ..........
                 from pt.
99143.........  Mod cs by same phys,  ......  N       ..........  ..........  ..........  ..........  ..........
                 < 5 yrs.
99144.........  Mod cs by same phys,  ......  N       ..........  ..........  ..........  ..........  ..........
                 5 yrs +.
99145.........  Mod cs by same phys   ......  N       ..........  ..........  ..........  ..........  ..........
                 add-on.
99148.........  Mod cs diff phys < 5  ......  N       ..........  ..........  ..........  ..........  ..........
                 yrs.
99149.........  Mod cs diff phys 5    ......  N       ..........  ..........  ..........  ..........  ..........
                 yrs +.
99150.........  Mod cs diff phys add- ......  N       ..........  ..........  ..........  ..........  ..........
                 on.
99170.........  Anogenital exam,      ......  T             0191      0.1468        9.02        2.55        1.80
                 child.
99175.........  Induction of          ......  N       ..........  ..........  ..........  ..........  ..........
                 vomiting.
99185.........  Regional hypothermia  ......  N       ..........  ..........  ..........  ..........  ..........
99186.........  Total body            ......  N       ..........  ..........  ..........  ..........  ..........
                 hypothermia.
99195.........  Phlebotomy..........  ......  X             0372      0.5723       35.18       10.09        7.04
99201.........  Office/outpatient      CH...  V             0604      0.8242       50.66  ..........       10.13
                 visit, new.
99202.........  Office/outpatient      CH...  V             0605       0.984       60.48  ..........       12.10
                 visit, new.
99203.........  Office/outpatient      CH...  V             0606      1.3646       83.88  ..........       16.78
                 visit, new.
99204.........  Office/outpatient      CH...  V             0607      1.7096      105.09  ..........       21.02
                 visit, new.
99205.........  Office/outpatient      CH...  V             0608      2.1794      133.96  ..........       26.79
                 visit, new.
99211.........  Office/outpatient      CH...  V             0604      0.8242       50.66  ..........       10.13
                 visit, est.
99212.........  Office/outpatient      CH...  V             0605       0.984       60.48  ..........       12.10
                 visit, est.
99213.........  Office/outpatient      CH...  V             0605       0.984       60.48  ..........       12.10
                 visit, est.
99214.........  Office/outpatient      CH...  V             0606      1.3646       83.88  ..........       16.78
                 visit, est.
99215.........  Office/outpatient      CH...  V             0607      1.7096      105.09  ..........       21.02
                 visit, est.
99241.........  Office consultation.   CH...  V             0604      0.8242       50.66  ..........       10.13
99242.........  Office consultation.   CH...  V             0605       0.984       60.48  ..........       12.10
99243.........  Office consultation.   CH...  V             0605       0.984       60.48  ..........       12.10
99244.........  Office consultation.   CH...  V             0606      1.3646       83.88  ..........       16.78
99245.........  Office consultation.   CH...  V             0607      1.7096      105.09  ..........       21.02
99281.........  Emergency dept visit   CH...  V             0609      0.8136       50.01       12.70       10.00
99282.........  Emergency dept visit   CH...  V             0613      1.3497       82.96       21.06       16.59
99283.........  Emergency dept visit   CH...  V             0614       2.115      130.00       34.50       26.00
99284.........  Emergency dept visit   CH...  V             0615      3.4163      209.99       48.49       42.00
99285.........  Emergency dept visit   CH...  V             0616      5.2915      325.26       75.11       65.05
99289.........  Ped crit care         ......  N       ..........  ..........  ..........  ..........  ..........
                 transport.
99290.........  Ped crit care         ......  N       ..........  ..........  ..........  ..........  ..........
                 transport addl.
99291.........  Critical care, first   CH...  S             0617      6.5894      405.04      111.59       81.01
                 hour.
99292.........  Critical care, add'l  ......  N       ..........  ..........  ..........  ..........  ..........
                 30 min.
99300.........  Ic, infant pbw 2501-  ......  N       ..........  ..........  ..........  ..........  ..........
                 5000 gm.
99354.........  Prolonged service,    ......  N       ..........  ..........  ..........  ..........  ..........
                 office.
99355.........  Prolonged service,    ......  N       ..........  ..........  ..........  ..........  ..........
                 office.
99358.........  Prolonged serv, w/o   ......  N       ..........  ..........  ..........  ..........  ..........
                 contact.
99359.........  Prolonged serv, w/o   ......  N       ..........  ..........  ..........  ..........  ..........
                 contact.
99361.........  Physician/team        ......  N       ..........  ..........  ..........  ..........  ..........
                 conference.
99362.........  Physician/team        ......  N       ..........  ..........  ..........  ..........  ..........
                 conference.
99363.........  Anticoag mgmt, init.   NI...  E       ..........  ..........  ..........  ..........  ..........
99364.........  Anticoag mgmt,         NI...  E       ..........  ..........  ..........  ..........  ..........
                 subseq.
99431.........  Initial care, normal   CH...  V             0605       0.984       60.48  ..........       12.10
                 newborn.
99432.........  Newborn care, not in  ......  N       ..........  ..........  ..........  ..........  ..........
                 hosp.
99436.........  Attendance, birth...  ......  N       ..........  ..........  ..........  ..........  ..........
99440.........  Newborn               ......  S             0094      2.4233      148.96       46.29       29.79
                 resuscitation.
0003T.........  Cervicography.......   CH...  D       ..........  ..........  ..........  ..........  ..........
0008T.........  Upper gi endoscopy w/  CH...  D       ..........  ..........  ..........  ..........  ..........
                 suture.

[[Page 68364]]

 
0012F.........  Cap bacterial assess   NI...  M       ..........  ..........  ..........  ..........  ..........
0016T.........  Thermotx choroid      ......  T             0235      3.9333      241.77       58.93       48.35
                 vasc lesion.
0017T.........  Photocoagulat         ......  T             0235      3.9333      241.77       58.93       48.35
                 macular drusen.
0018T.........  Transcranial           CH...  D       ..........  ..........  ..........  ..........  ..........
                 magnetic stimul.
0021T.........  Fetal oximetry,        CH...  D       ..........  ..........  ..........  ..........  ..........
                 trnsvag/cerv.
0027T.........  Endoscopic epidural   ......  T             0220     17.8499    1,097.20  ..........      219.44
                 lysis.
0028T.........  Dexa body             ......  N       ..........  ..........  ..........  ..........  ..........
                 composition study.
0031T.........  Speculoscopy........  ......  N       ..........  ..........  ..........  ..........  ..........
0032T.........  Speculoscopy w/       ......  N       ..........  ..........  ..........  ..........  ..........
                 direct sample.
0042T.........  Ct perfusion w/       ......  N       ..........  ..........  ..........  ..........  ..........
                 contrast, cbf.
0044T.........  Whole body             CH...  D       ..........  ..........  ..........  ..........  ..........
                 photography.
0045T.........  Whole body             CH...  D       ..........  ..........  ..........  ..........  ..........
                 photography.
0046T.........  Cath lavage, mammary  ......  T             0021     15.1024      928.31      219.48      185.66
                 duct(s).
0047T.........  Cath lavage, mammary  ......  T             0021     15.1024      928.31      219.48      185.66
                 duct(s).
0054T.........  Bone surgery using    ......  S             0302      4.9138      302.04      105.94       60.41
                 computer.
0055T.........  Bone surgery using    ......  S             0302      4.9138      302.04      105.94       60.41
                 computer.
0056T.........  Bone surgery using    ......  S             0302      4.9138      302.04      105.94       60.41
                 computer.
0058T.........  Cryopreservation,     ......  X             0348      0.8321       51.15  ..........       10.23
                 ovary tiss.
0059T.........  Cryopreservation,     ......  X             0348      0.8321       51.15  ..........       10.23
                 oocyte.
0062T.........  Rep intradisc         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 annulus;1 lev.
0063T.........  Rep intradisc         ......  T             0050     25.1296    1,544.67  ..........      308.93
                 annulus;>1lev.
0064T.........  Spectroscop eval      ......  X             0367      0.6277       38.58       14.68        7.72
                 expired gas.
0067T.........  Ct colonography;dx..  ......  S             0333      4.8405      297.54      119.01       59.51
0069T.........  Analysis only heart   ......  N       ..........  ..........  ..........  ..........  ..........
                 sound.
0071T.........  U/s leiomyomata       ......  T             0195     28.5095    1,752.42      483.80      350.48
                 ablate <200.
0072T.........  U/s leiomyomata       ......  T             0202     42.9896    2,642.48      981.50      528.50
                 ablate >200.
0073T.........  Delivery, comp imrt.  ......  S             0412      5.4731      336.42  ..........       67.28
0082T.........  Stereotactic rad       CH...  D       ..........  ..........  ..........  ..........  ..........
                 delivery.
0083T.........  Stereotactic rad tx    CH...  D       ..........  ..........  ..........  ..........  ..........
                 mngmt.
0084T.........  Temp prostate         ......  T             0164      2.1393      131.50  ..........       26.30
                 urethral stent.
0085T.........  Breath test heart     ......  X             0340      0.6102       37.51  ..........        7.50
                 reject.
0086T.........  Lventricle fill       ......  N       ..........  ..........  ..........  ..........  ..........
                 pressure.
0087T.........  Sperm eval            ......  X             0348      0.8321       51.15  ..........       10.23
                 hyaluronan.
0088T.........  Rf tongue base vol    ......  T             0253     16.4266    1,009.71      282.29      201.94
                 reduxn.
0089T.........  Actigraphy testing,   ......  S             0218      1.1872       72.97  ..........       14.59
                 3-day.
0090T.........  Cervical artific       CH...  E       ..........  ..........  ..........  ..........  ..........
                 disc.
0091T.........  Lumbar artific disc.   CH...  D       ..........  ..........  ..........  ..........  ..........
0094T.........  Lumbar artific         CH...  D       ..........  ..........  ..........  ..........  ..........
                 diskectomy.
0097T.........  Rev lumbar artific     CH...  D       ..........  ..........  ..........  ..........  ..........
                 disc.
0099T.........  Implant corneal ring  ......  T             0233     15.2259      935.91      266.33      187.18
0100T.........  Prosth retina         ......  T             0672      37.429    2,300.69  ..........      460.14
                 receive&gen.
0101T.........  Extracorp shockwv      CH...  T             0050     25.1296    1,544.67  ..........      308.93
                 tx,hi enrg.
0102T.........  Extracorp shockwv      CH...  T             0050     25.1296    1,544.67  ..........      308.93
                 tx,anesth.
0106T.........  Touch quant sensory   ......  X             0341      0.0914        5.62        2.24        1.12
                 test.
0107T.........  Vibrate quant         ......  X             0341      0.0914        5.62        2.24        1.12
                 sensory test.
0108T.........  Cool quant sensory    ......  X             0341      0.0914        5.62        2.24        1.12
                 test.
0109T.........  Heat quant sensory    ......  X             0341      0.0914        5.62        2.24        1.12
                 test.
0110T.........  Nos quant sensory     ......  X             0341      0.0914        5.62        2.24        1.12
                 test.
0120T.........  Fibroadenoma           CH...  D       ..........  ..........  ..........  ..........  ..........
                 cryoablate, ea.
0123T.........  Scleral               ......  T             0234      22.997    1,413.58      511.31      282.72
                 fistulization.
0124T.........  Conjunctival drug     ......  T             0232      6.0673      372.94       93.43       74.59
                 placement.
0126T.........  Chd risk imt study..  ......  N       ..........  ..........  ..........  ..........  ..........
0133T.........  Esophageal implant     CH...  T             0422     25.7552    1,583.12      448.81      316.62
                 injexn.
0135T.........  Perq cryoablate        CH...  T             0423     37.3604    2,296.47  ..........      459.29
                 renal tumor.
0137T.........  Prostate saturation   ......  T             0184      5.6262      345.83       96.27       69.17
                 sampling.
0144T.........  CT heart wo dye;      ......  S             0398      4.1265      253.65      100.06       50.73
                 qual calc.
0145T.........  CT heart w/wo dye     ......  S             0376      4.9832      306.31      119.77       61.26
                 funct.
0146T.........  CCTA w/wo dye.......  ......  S             0376      4.9832      306.31      119.77       61.26
0147T.........  CCTA w/wo, quan       ......  S             0376      4.9832      306.31      119.77       61.26
                 calcium.
0148T.........  CCTA w/wo, strxr....  ......  S             0377      6.5012      399.62      158.84       79.92
0149T.........  CCTA w/wo, strxr      ......  S             0377      6.5012      399.62      158.84       79.92
                 quan calc.
0150T.........  CCTA w/wo, disease    ......  S             0398      4.1265      253.65      100.06       50.73
                 strxr.
0151T.........  CT heart funct add-   ......  S             0282      1.5379       94.53       37.81       18.91
                 on.
0152T.........  Computer chest add-   ......  N       ..........  ..........  ..........  ..........  ..........
                 on.
0154T.........  Study sensor          ......  X             0097      1.0225       62.85       23.79       12.57
                 aneurysm sac.
0155T.........  Lap impl gast curve    NF...  T             0130     32.1241    1,974.60      659.53      394.92
                 electrd.
0156T.........  Lap remv gast curve    NF...  T             0130     32.1241    1,974.60      659.53      394.92
                 electrd.
0157T.........  Open impl gast curve   NF...  C       ..........  ..........  ..........  ..........  ..........
                 electrd.
0158T.........  Open remv gast curve   NF...  C       ..........  ..........  ..........  ..........  ..........
                 electrd.
0159T.........  Cad breast mri......   NF...  N       ..........  ..........  ..........  ..........  ..........

[[Page 68365]]

 
0160T.........  Tcranial magn stim     CH...  S             0216      2.7199      167.19  ..........       33.44
                 tx plan.
0161T.........  Tcranial magn stim     CH...  S             0216      2.7199      167.19  ..........       33.44
                 tx deliv.
0162T.........  Anal program gast      NI...  S             0692      1.9323      118.77       30.16       23.75
                 neurostim.
0163T.........  Lumb artif             NI...  C       ..........  ..........  ..........  ..........  ..........
                 diskectomy addl.
0164T.........  Remove lumb artif      NI...  C       ..........  ..........  ..........  ..........  ..........
                 disc addl.
0165T.........  Revise lumb artif      NI...  C       ..........  ..........  ..........  ..........  ..........
                 disc addl.
0166T.........  Tcath vsd close w/o    NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass.
0167T.........  Tcath vsd close w      NI...  C       ..........  ..........  ..........  ..........  ..........
                 bypass.
0168T.........  Rhinophototx light     NI...  T             0251       2.452      150.72  ..........       30.14
                 app bilat.
0169T.........  Place stereo cath      NI...  C       ..........  ..........  ..........  ..........  ..........
                 brain.
0170T.........  Anorectal fistula      NI...  T             0150     29.6189    1,820.61      437.12      364.12
                 plug rpr.
0171T.........  Lumbar spine proces    NI...  T             0050     25.1296    1,544.67  ..........      308.93
                 distract.
0172T.........  Lumbar spine proces    NI...  T             0050     25.1296    1,544.67  ..........      308.93
                 addl.
0173T.........  Iop monit io           NI...  N       ..........  ..........  ..........  ..........  ..........
                 pressure.
0174T.........  Cad cxr with interp.   NI...  N       ..........  ..........  ..........  ..........  ..........
0175T.........  Cad cxr remote......   NI...  N       ..........  ..........  ..........  ..........  ..........
0176T.........  Aqu canal dilat w/o    NI...  T             0673     37.8967    2,329.43      649.56      465.89
                 retent.
0177T.........  Aqu canal dilat w      NI...  T             0673     37.8967    2,329.43      649.56      465.89
                 retent.
0505F.........  Hemodialysis plan      NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc'd.
0507F.........  Periton dialysis       NI...  M       ..........  ..........  ..........  ..........  ..........
                 plan doc'd.
1001F.........  Tobacco use, non-      CH...  D       ..........  ..........  ..........  ..........  ..........
                 smoking.
1015F.........  Copd symptoms assess   NI...  M       ..........  ..........  ..........  ..........  ..........
1018F.........  Assess dyspnea not     NI...  M       ..........  ..........  ..........  ..........  ..........
                 present.
1019F.........  Assess dyspnea         NI...  M       ..........  ..........  ..........  ..........  ..........
                 present.
1022F.........  Pneumo imm status      NI...  M       ..........  ..........  ..........  ..........  ..........
                 assess.
1026F.........  Co-morbid condition    NI...  M       ..........  ..........  ..........  ..........  ..........
                 assess.
1030F.........  Influenza imm status   NI...  M       ..........  ..........  ..........  ..........  ..........
                 assess.
1034F.........  Current tobacco        NI...  M       ..........  ..........  ..........  ..........  ..........
                 smoker.
1035F.........  Smokeless tobacco      NI...  M       ..........  ..........  ..........  ..........  ..........
                 user.
1036F.........  Tobacco non-user....   NI...  M       ..........  ..........  ..........  ..........  ..........
1038F.........  Persistent asthma...   NI...  M       ..........  ..........  ..........  ..........  ..........
1039F.........  Intermittent asthma.   NI...  M       ..........  ..........  ..........  ..........  ..........
1040F.........  Dsm-iv[Ouml] info      NI...  M       ..........  ..........  ..........  ..........  ..........
                 mdd doc'd.
2003F.........  Auscultation heart     CH...  D       ..........  ..........  ..........  ..........  ..........
                 perform.
2010F.........  Vital signs recorded   NI...  M       ..........  ..........  ..........  ..........  ..........
2014F.........  Mental status assess   NI...  M       ..........  ..........  ..........  ..........  ..........
2018F.........  Hydration status       NI...  M       ..........  ..........  ..........  ..........  ..........
                 assess.
2022F.........  Dil retina exam        NI...  M       ..........  ..........  ..........  ..........  ..........
                 interp rev.
2024F.........  7 field photo interp   NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc rev.
2026F.........  Eye image valid to     NI...  M       ..........  ..........  ..........  ..........  ..........
                 dx rev.
2028F.........  Foot exam performed.   NI...  M       ..........  ..........  ..........  ..........  ..........
2030F.........  H2O stat               NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc[AElig]d, normal.
2031F.........  H2O stat               NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc[AElig]d,
                 dehydrated.
3000F.........  Blood press [lE] 140/  CH...  D       ..........  ..........  ..........  ..........  ..........
                 90 mmhg.
3002F.........  Blood pressure > 140/  CH...  D       ..........  ..........  ..........  ..........  ..........
                 90 mmhg.
3006F.........  Cxr doc rev.........   NI...  M       ..........  ..........  ..........  ..........  ..........
3011F.........  Lipid panel doc rev.   NI...  M       ..........  ..........  ..........  ..........  ..........
3014F.........  Screen mammo doc rev   NI...  M       ..........  ..........  ..........  ..........  ..........
3017F.........  Colorectal ca screen   NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc rev.
3020F.........  Lvf assess..........   NI...  M       ..........  ..........  ..........  ..........  ..........
3021F.........  Lvef mod/sever deprs   NI...  M       ..........  ..........  ..........  ..........  ..........
                 syst.
3022F.........  Lvef ?40% systolic..   NI...  M       ..........  ..........  ..........  ..........  ..........
3023F.........  Spirom doc rev......   NI...  M       ..........  ..........  ..........  ..........  ..........
3025F.........  Spirom fev/fvc<70% w   NI...  M       ..........  ..........  ..........  ..........  ..........
                 copd.
3027F.........  Spirom fev/fvc?70%/    NI...  M       ..........  ..........  ..........  ..........  ..........
                 w/o copd.
3028F.........  O2 saturation doc      NI...  M       ..........  ..........  ..........  ..........  ..........
                 rev.
3035F.........  O2 saturation ?88% /   NI...  M       ..........  ..........  ..........  ..........  ..........
                 pa0 ?55.
3037F.........  O2 saturation> 88% /   NI...  M       ..........  ..........  ..........  ..........  ..........
                 pa0>55.
3040F.........  Fev<40% predicted      NI...  M       ..........  ..........  ..........  ..........  ..........
                 value.
3042F.........  Fev? 40% predicted     NI...  M       ..........  ..........  ..........  ..........  ..........
                 value.
3046F.........  Hemoglobin a1c level   NI...  M       ..........  ..........  ..........  ..........  ..........
                 > 9.0%.
3047F.........  Hemoglobin A1c level   NI...  M       ..........  ..........  ..........  ..........  ..........
                 ? 9.0%.
3048F.........  LDL-C <100 mg/dL....   NI...  M       ..........  ..........  ..........  ..........  ..........
3049F.........  LDL-C 100-129 mg/dL.   NI...  M       ..........  ..........  ..........  ..........  ..........
3050F.........  LDL-C ? 130 mg/dL...   NI...  M       ..........  ..........  ..........  ..........  ..........
3060F.........  Pos microalbuminuria   NI...  M       ..........  ..........  ..........  ..........  ..........
                 rev.
3061F.........  Neg microalbuminuria   NI...  M       ..........  ..........  ..........  ..........  ..........
                 rev.
3062F.........  Pos macroalbuminuria   NI...  M       ..........  ..........  ..........  ..........  ..........
                 rev.
3066F.........  Nephropathy doc tx..   NI...  M       ..........  ..........  ..........  ..........  ..........
3072F.........  Low risk for           NI...  M       ..........  ..........  ..........  ..........  ..........
                 retinopathy.

[[Page 68366]]

 
3076F.........  Syst bp < 140 mm hg.   NI...  M       ..........  ..........  ..........  ..........  ..........
3077F.........  Syst bp ? 140 mm hg.   NI...  M       ..........  ..........  ..........  ..........  ..........
3078F.........  Diast bp < 80 mm hg.   NI...  M       ..........  ..........  ..........  ..........  ..........
3079F.........  Diast bp 80-89 mm hg   NI...  M       ..........  ..........  ..........  ..........  ..........
3080F.........  Diast bp ? 90 mm hg.   NI...  M       ..........  ..........  ..........  ..........  ..........
3082F.........  Kt/v <1.2...........   NI...  M       ..........  ..........  ..........  ..........  ..........
3083F.........  Kt/v [gE] 1.2 and      NI...  M       ..........  ..........  ..........  ..........  ..........
                 <1.7.
3084F.........  Kt/v ? 1.7..........   NI...  M       ..........  ..........  ..........  ..........  ..........
3085F.........  Suicide risk           NI...  M       ..........  ..........  ..........  ..........  ..........
                 assessed.
3088F.........  Mdd, mild...........   NI...  M       ..........  ..........  ..........  ..........  ..........
3089F.........  Mdd, moderate.......   NI...  M       ..........  ..........  ..........  ..........  ..........
3090F.........  Mdd, severe; w/o       NI...  M       ..........  ..........  ..........  ..........  ..........
                 psych.
3091F.........  Mdd, severe; w/        NI...  M       ..........  ..........  ..........  ..........  ..........
                 psych.
3092F.........  Mdd, in remission...   NI...  M       ..........  ..........  ..........  ..........  ..........
3093F.........  Doc new diag 1st/      NI...  M       ..........  ..........  ..........  ..........  ..........
                 addl. mdd.
4025F.........  Inhaled                NI...  M       ..........  ..........  ..........  ..........  ..........
                 broncholidator rx.
4030F.........  Oxygen therapy rx...   NI...  M       ..........  ..........  ..........  ..........  ..........
4033F.........  Pulmonary rehab rec.   NI...  M       ..........  ..........  ..........  ..........  ..........
4035F.........  Influenza imm rec...   NI...  M       ..........  ..........  ..........  ..........  ..........
4037F.........  Influenza imm order/   NI...  M       ..........  ..........  ..........  ..........  ..........
                 admin.
4040F.........  pneumoc imm order/     NI...  M       ..........  ..........  ..........  ..........  ..........
                 admin.
4045F.........  Empiric antibiotic     NI...  M       ..........  ..........  ..........  ..........  ..........
                 rx.
4050F.........  Ht care plan doc....   NI...  M       ..........  ..........  ..........  ..........  ..........
4051F.........  Referred for an av     NI...  M       ..........  ..........  ..........  ..........  ..........
                 fistula.
4052F.........  Hemodialysis via av    NI...  M       ..........  ..........  ..........  ..........  ..........
                 fistula.
4053F.........  Hemodialysis via av    NI...  M       ..........  ..........  ..........  ..........  ..........
                 graft.
4054F.........  Hemodialysis via       NI...  M       ..........  ..........  ..........  ..........  ..........
                 catheter.
4055F.........  Pt. rcvng periton      NI...  M       ..........  ..........  ..........  ..........  ..........
                 dialysis.
4056F.........  Approp. oral rehyd.    NI...  M       ..........  ..........  ..........  ..........  ..........
                 recomm[AElig]d.
4058F.........  Ped gastro ed given,   NI...  M       ..........  ..........  ..........  ..........  ..........
                 caregvr.
4060F.........  Psych svcs provided.   NI...  M       ..........  ..........  ..........  ..........  ..........
4062F.........  Pt referral psych      NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc[AElig]d.
4064F.........  Antidepressant rx...   NI...  M       ..........  ..........  ..........  ..........  ..........
4065F.........  Antipsychotic rx....   NI...  M       ..........  ..........  ..........  ..........  ..........
4066F.........  Ect provided........   NI...  M       ..........  ..........  ..........  ..........  ..........
4067F.........  Pt referral for ect    NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc[AElig]d.
6005F.........  Care level rationale   NI...  M       ..........  ..........  ..........  ..........  ..........
                 doc.
A0800.........  Amb trans 7pm-7am...   CH...  D       ..........  ..........  ..........  ..........  ..........
A4211.........  Supp for self-adm      CH...  E       ..........  ..........  ..........  ..........  ..........
                 injections.
A4218.........  Sterile saline or     ......  N       ..........  ..........  ..........  ..........  ..........
                 water.
A4220.........  Infusion pump refill  ......  N       ..........  ..........  ..........  ..........  ..........
                 kit.
A4248.........  Chlorhexidine         ......  N       ..........  ..........  ..........  ..........  ..........
                 antisept.
A4262.........  Temporary tear duct   ......  N       ..........  ..........  ..........  ..........  ..........
                 plug.
A4263.........  Permanent tear duct   ......  N       ..........  ..........  ..........  ..........  ..........
                 plug.
A4270.........  Disposable endoscope  ......  N       ..........  ..........  ..........  ..........  ..........
                 sheath.
A4300.........  Cath impl vasc        ......  N       ..........  ..........  ..........  ..........  ..........
                 access portal.
A4301.........  Implantable access    ......  N       ..........  ..........  ..........  ..........  ..........
                 syst perc.
A4305.........  Drug delivery system   CH...  N       ..........  ..........  ..........  ..........  ..........
                 [gE]50 ML.
A4306.........  Drug delivery system   CH...  N       ..........  ..........  ..........  ..........  ..........
                 [lE]50 ml.
A4348.........  Male ext cath          CH...  D       ..........  ..........  ..........  ..........  ..........
                 extended wear.
A4359.........  Urinary suspensory w/  CH...  D       ..........  ..........  ..........  ..........  ..........
                 o leg b.
A4461.........  Surgicl dress hold     NI...  A       ..........  ..........  ..........  ..........  ..........
                 non-reuse.
A4462.........  Abdmnl drssng holder/  CH...  D       ..........  ..........  ..........  ..........  ..........
                 binder.
A4463.........  Surgical dress         NI...  A       ..........  ..........  ..........  ..........  ..........
                 holder reuse.
A4559.........  Coupling gel or        NI...  Y       ..........  ..........  ..........  ..........  ..........
                 paste.
A4561.........  Pessary rubber, any   ......  N       ..........  ..........  ..........  ..........  ..........
                 type.
A4562.........  Pessary, non          ......  N       ..........  ..........  ..........  ..........  ..........
                 rubber,any type.
A4600.........  Sleeve, inter limb     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 comp dev.
A4601.........  Lith ion batt, non-    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 pros use.
A4614.........  Hand-held PEFR meter   CH...  N       ..........  ..........  ..........  ..........  ..........
A4632.........  Infus pump rplcemnt    CH...  D       ..........  ..........  ..........  ..........  ..........
                 battery.
A4641.........  Radiopharm dx agent   ......  N       ..........  ..........  ..........  ..........  ..........
                 noc.
A4642.........  In111 satumomab.....  ......  H             0704  ..........  ..........  ..........  ..........
A5512.........  Multi den insert       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 direct form.
A5513.........  Multi den insert       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 custom mold.
A8000.........  Soft protect helmet    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 prefab.
A8001.........  Hard protect helmet    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 prefab.
A8002.........  Soft protect helmet    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 custom.
A8003.........  Hard protect helmet    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 custom.
A8004.........  Repl soft interface,   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 helmet.

[[Page 68367]]

 
A9279.........  Monitoring feature/    NI...  E       ..........  ..........  ..........  ..........  ..........
                 deviceNOC.
A9500.........  Tc99m sestamibi.....  ......  H             1600  ..........  ..........  ..........  ..........
A9502.........  Tc99m tetrofosmin...  ......  H             0705  ..........  ..........  ..........  ..........
A9503.........  Tc99m medronate.....  ......  N       ..........  ..........  ..........  ..........  ..........
A9504.........  Tc99m apcitide......   CH...  N       ..........  ..........  ..........  ..........  ..........
A9505.........  TL201 thallium......  ......  H             1603  ..........  ..........  ..........  ..........
A9507.........  In111 capromab......  ......  H             1604  ..........  ..........  ..........  ..........
A9508.........  I131 iodobenguate,    ......  H             1045  ..........  ..........  ..........  ..........
                 dx.
A9510.........  Tc99m disofenin.....   CH...  N       ..........  ..........  ..........  ..........  ..........
A9512.........  Tc99m pertechnetate.  ......  N       ..........  ..........  ..........  ..........  ..........
A9516.........  I123 iodide cap, dx.   CH...  H             9148  ..........  ..........  ..........  ..........
A9517.........  I131 iodide cap, rx.   CH...  H             1064  ..........  ..........  ..........  ..........
A9521.........  Tc99m exametazime...  ......  H             1096  ..........  ..........  ..........  ..........
A9524.........  I131 serum albumin,   ......  H             9100  ..........  ..........  ..........  ..........
                 dx.
A9526.........  Nitrogen N-13         ......  H             0737  ..........  ..........  ..........  ..........
                 ammonia.
A9527.........  Iodine I-125 sodium    NI...  K             2632      0.3321       20.41  ..........        4.08
                 iodide.
A9528.........  Iodine I-131 iodide   ......  H             1088  ..........  ..........  ..........  ..........
                 cap, dx.
A9529.........  I131 iodide sol, dx.   CH...  N       ..........  ..........  ..........  ..........  ..........
A9530.........  I131 iodide sol, rx.  ......  H             1150  ..........  ..........  ..........  ..........
A9531.........  I131 max 100uCi.....   CH...  N       ..........  ..........  ..........  ..........  ..........
A9532.........  I125 serum albumin,    CH...  N       ..........  ..........  ..........  ..........  ..........
                 dx.
A9535.........  Injection, methylene   CH...  N       ..........  ..........  ..........  ..........  ..........
                 blue.
A9536.........  Tc99m depreotide....   CH...  H             0739  ..........  ..........  ..........  ..........
A9537.........  Tc99m mebrofenin....  ......  N       ..........  ..........  ..........  ..........  ..........
A9538.........  Tc99m pyrophosphate.  ......  N       ..........  ..........  ..........  ..........  ..........
A9539.........  Tc99m pentetate.....   CH...  H             0722  ..........  ..........  ..........  ..........
A9540.........  Tc99m MAA...........  ......  N       ..........  ..........  ..........  ..........  ..........
A9541.........  Tc99m sulfur colloid  ......  N       ..........  ..........  ..........  ..........  ..........
A9542.........  In111 ibritumomab,    ......  H             1642  ..........  ..........  ..........  ..........
                 dx.
A9543.........  Y90 ibritumomab, rx.  ......  H             1643  ..........  ..........  ..........  ..........
A9544.........  I131 tositumomab, dx  ......  H             1644  ..........  ..........  ..........  ..........
A9545.........  I131 tositumomab, rx  ......  H             1645  ..........  ..........  ..........  ..........
A9546.........  Co57/58.............   CH...  H             0723  ..........  ..........  ..........  ..........
A9547.........  In111 oxyquinoline..  ......  H             1646  ..........  ..........  ..........  ..........
A9548.........  In111 pentetate.....  ......  H             1647  ..........  ..........  ..........  ..........
A9549.........  Tc99m arcitumomab...   CH...  D       ..........  ..........  ..........  ..........  ..........
A9550.........  Tc99m gluceptate....   CH...  H             0740  ..........  ..........  ..........  ..........
A9551.........  Tc99m succimer......  ......  H             1650  ..........  ..........  ..........  ..........
A9552.........  F18 fdg.............  ......  H             1651  ..........  ..........  ..........  ..........
A9553.........  Cr51 chromate.......   CH...  H             0741  ..........  ..........  ..........  ..........
A9554.........  I125 iothalamate, dx   CH...  N       ..........  ..........  ..........  ..........  ..........
A9555.........  Rb82 rubidium.......  ......  H             1654  ..........  ..........  ..........  ..........
A9556.........  Ga67 gallium........  ......  H             1671  ..........  ..........  ..........  ..........
A9557.........  Tc99m bicisate......  ......  H             1672  ..........  ..........  ..........  ..........
A9558.........  Xe133 xenon 10mci...  ......  N       ..........  ..........  ..........  ..........  ..........
A9559.........  Co57 cyano..........   CH...  H             0724  ..........  ..........  ..........  ..........
A9560.........  Tc99m labeled rbc...   CH...  H             0742  ..........  ..........  ..........  ..........
A9561.........  Tc99m oxidronate....  ......  N       ..........  ..........  ..........  ..........  ..........
A9562.........  Tc99m mertiatide....   CH...  H             0743  ..........  ..........  ..........  ..........
A9563.........  P32 Na phosphate....  ......  H             1675  ..........  ..........  ..........  ..........
A9564.........  P32 chromic           ......  H             1676  ..........  ..........  ..........  ..........
                 phosphate.
A9565.........  In111 pentetreotide.  ......  H             1677  ..........  ..........  ..........  ..........
A9566.........  Tc99m fanolesomab...  ......  H             1678  ..........  ..........  ..........  ..........
A9567.........  Technetium TC-99m      CH...  H             0829  ..........  ..........  ..........  ..........
                 aerosol.
A9568.........  Technetium tc99m       NI...  H             1648  ..........  ..........  ..........  ..........
                 arcitumomab.
A9600.........  Sr89 strontium......  ......  H             0701  ..........  ..........  ..........  ..........
A9605.........  Sm 153 lexidronm....  ......  H             0702  ..........  ..........  ..........  ..........
A9698.........  Non-rad contrast      ......  N       ..........  ..........  ..........  ..........  ..........
                 materialNOC.
A9699.........  Radiopharm rx agent   ......  N       ..........  ..........  ..........  ..........  ..........
                 noc.
A9900.........  Supply/accessory/      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 service.
B4034.........  Enter feed supkit      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 syr by day.
B4035.........  Enteral feed supp      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 pump per d.
B4036.........  Enteral feed sup kit   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 grav by.
B4081.........  Enteral ng tubing w/   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 stylet.
B4082.........  Enteral ng tubing w/   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 o stylet.
B4083.........  Enteral stomach tube   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 levine.
B4086.........  Gastrostomy/           CH...  Y       ..........  ..........  ..........  ..........  ..........
                 jejunostomy tube.
B4102.........  EF adult fluids and    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 electro.
B4103.........  EF ped fluid and       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 electrolyte.
B4149.........  EF blenderized foods   CH...  Y       ..........  ..........  ..........  ..........  ..........

[[Page 68368]]

 
B4150.........  EF complet w/intact    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 nutrient.
B4152.........  EF calorie             CH...  Y       ..........  ..........  ..........  ..........  ..........
                 dense[gE]1.5Kcal.
B4153.........  EF hydrolyzed/amino    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acids.
B4154.........  EF spec metabolic      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 noninherit.
B4155.........  EF incomplete/         CH...  Y       ..........  ..........  ..........  ..........  ..........
                 modular.
B4157.........  EF special metabolic   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 inherit.
B4158.........  EF ped complete        CH...  Y       ..........  ..........  ..........  ..........  ..........
                 intact nut.
B4159.........  EF ped complete soy    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 based.
B4160.........  EF ped caloric         CH...  Y       ..........  ..........  ..........  ..........  ..........
                 dense[gE]0.7kc.
B4161.........  EF ped hydrolyzed/     CH...  Y       ..........  ..........  ..........  ..........  ..........
                 amino acid.
B4162.........  EF ped specmetabolic   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 inherit.
B4164.........  Parenteral 50%         CH...  Y       ..........  ..........  ..........  ..........  ..........
                 dextrose solu.
B4168.........  Parenteral sol amino   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acid 3..
B4172.........  Parenteral sol amino   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acid 5..
B4176.........  Parenteral sol amino   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acid 7-.
B4178.........  Parenteral sol amino   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acid >.
B4180.........  Parenteral sol carb    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 > 50%.
B4189.........  Parenteral sol amino   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 acid &.
B4193.........  Parenteral sol 52-73   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 gm prot.
B4197.........  Parenteral sol 74-     CH...  Y       ..........  ..........  ..........  ..........  ..........
                 100 gm pro.
B4199.........  Parenteral sol >       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 100gm prote.
B4216.........  Parenteral nutrition   CH...  Y       ..........  ..........  ..........  ..........  ..........
                 additiv.
B4220.........  Parenteral supply      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 kit premix.
B4222.........  Parenteral supply      CH...  Y       ..........  ..........  ..........  ..........  ..........
                 kit homemi.
B4224.........  Parenteral             CH...  Y       ..........  ..........  ..........  ..........  ..........
                 administration ki.
B5000.........  Parenteral sol renal-  CH...  Y       ..........  ..........  ..........  ..........  ..........
                 amirosy.
B5100.........  Parenteral sol         CH...  Y       ..........  ..........  ..........  ..........  ..........
                 hepatic-fream.
B5200.........  Parenteral sol stres-  CH...  Y       ..........  ..........  ..........  ..........  ..........
                 brnch c.
B9000.........  Enter infusion pump    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 w/o alrm.
B9002.........  Enteral infusion       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 pump w/ ala.
B9004.........  Parenteral infus       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 pump portab.
B9006.........  Parenteral infus       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 pump statio.
B9998.........  Enteral supp not       CH...  Y       ..........  ..........  ..........  ..........  ..........
                 otherwise c.
B9999.........  Parenteral supp not    CH...  Y       ..........  ..........  ..........  ..........  ..........
                 othrws c.
C1178.........  BUSULFAN IV, 6 Mg...   CH...  D       ..........  ..........  ..........  ..........  ..........
C1300.........  HYPERBARIC Oxygen...  ......  S             0659      1.5906       97.77  ..........       19.55
C1713.........  Anchor/screw bn/      ......  N       ..........  ..........  ..........  ..........  ..........
                 bn,tis/bn.
C1714.........  Cath, trans           ......  N       ..........  ..........  ..........  ..........  ..........
                 atherectomy, dir.
C1715.........  Brachytherapy needle  ......  N       ..........  ..........  ..........  ..........  ..........
C1716.........  Brachytx source,       CH...  K             1716      0.5991       36.83  ..........        7.37
                 Gold 198.
C1717.........  Brachytx source, HDR   CH...  K             1717      2.3195      142.58  ..........       28.52
                 Ir-192.
C1718.........  Brachytx source,       CH...  K             1718       0.591       36.33  ..........        7.27
                 Iodine 125.
C1719.........  Brachytx sour,Non-     CH...  K             1719      0.3765       23.14  ..........        4.63
                 HDR Ir-192.
C1720.........  Brachytx sour,         CH...  K             1720      0.7942       48.82  ..........        9.76
                 Palladium 103.
C1721.........  AICD, dual chamber..  ......  N       ..........  ..........  ..........  ..........  ..........
C1722.........  AICD, single chamber  ......  N       ..........  ..........  ..........  ..........  ..........
C1724.........  Cath, trans           ......  N       ..........  ..........  ..........  ..........  ..........
                 atherec,rotation.
C1725.........  Cath, translumin non- ......  N       ..........  ..........  ..........  ..........  ..........
                 laser.
C1726.........  Cath, bal dil, non-   ......  N       ..........  ..........  ..........  ..........  ..........
                 vascular.
C1727.........  Cath, bal tis dis,    ......  N       ..........  ..........  ..........  ..........  ..........
                 non-vas.
C1728.........  Cath, brachytx seed   ......  N       ..........  ..........  ..........  ..........  ..........
                 adm.
C1729.........  Cath, drainage......  ......  N       ..........  ..........  ..........  ..........  ..........
C1730.........  Cath, EP, 19 or few   ......  N       ..........  ..........  ..........  ..........  ..........
                 elect.
C1731.........  Cath, EP, 20 or more  ......  N       ..........  ..........  ..........  ..........  ..........
                 elec.
C1732.........  Cath, EP, diag/abl,   ......  N       ..........  ..........  ..........  ..........  ..........
                 3D/vect.
C1733.........  Cath, EP, othr than   ......  N       ..........  ..........  ..........  ..........  ..........
                 cool-tip.
C1750.........  Cath,                 ......  N       ..........  ..........  ..........  ..........  ..........
                 hemodialysis,long-
                 term.
C1751.........  Cath, inf, per/cent/  ......  N       ..........  ..........  ..........  ..........  ..........
                 midline.
C1752.........  Cath,hemodialysis,sh  ......  N       ..........  ..........  ..........  ..........  ..........
                 ort-term.
C1753.........  Cath, intravas        ......  N       ..........  ..........  ..........  ..........  ..........
                 ultrasound.
C1754.........  Catheter,             ......  N       ..........  ..........  ..........  ..........  ..........
                 intradiscal.
C1755.........  Catheter,             ......  N       ..........  ..........  ..........  ..........  ..........
                 intraspinal.
C1756.........  Cath, pacing,         ......  N       ..........  ..........  ..........  ..........  ..........
                 transesoph.
C1757.........  Cath, thrombectomy/   ......  N       ..........  ..........  ..........  ..........  ..........
                 embolect.
C1758.........  Catheter, ureteral..  ......  N       ..........  ..........  ..........  ..........  ..........
C1759.........  Cath, intra           ......  N       ..........  ..........  ..........  ..........  ..........
                 echocardiography.
C1760.........  Closure dev, vasc...  ......  N       ..........  ..........  ..........  ..........  ..........
C1762.........  Conn tiss, human(inc  ......  N       ..........  ..........  ..........  ..........  ..........
                 fascia).
C1763.........  Conn tiss, non-human  ......  N       ..........  ..........  ..........  ..........  ..........
C1764.........  Event recorder,       ......  N       ..........  ..........  ..........  ..........  ..........
                 cardiac.

[[Page 68369]]

 
C1765.........  Adhesion barrier....  ......  N       ..........  ..........  ..........  ..........  ..........
C1766.........  Intro/                ......  N       ..........  ..........  ..........  ..........  ..........
                 sheath,strble,non-
                 peel.
C1767.........  Generator, neuro non- ......  N       ..........  ..........  ..........  ..........  ..........
                 recharg.
C1768.........  Graft, vascular.....  ......  N       ..........  ..........  ..........  ..........  ..........
C1769.........  Guide wire..........  ......  N       ..........  ..........  ..........  ..........  ..........
C1770.........  Imaging coil, MR,     ......  N       ..........  ..........  ..........  ..........  ..........
                 insertable.
C1771.........  Rep dev, urinary, w/  ......  N       ..........  ..........  ..........  ..........  ..........
                 sling.
C1772.........  Infusion pump,        ......  N       ..........  ..........  ..........  ..........  ..........
                 programmable.
C1773.........  Ret dev, insertable.  ......  N       ..........  ..........  ..........  ..........  ..........
C1776.........  Joint device          ......  N       ..........  ..........  ..........  ..........  ..........
                 (implantable).
C1777.........  Lead, AICD, endo      ......  N       ..........  ..........  ..........  ..........  ..........
                 single coil.
C1778.........  Lead,                 ......  N       ..........  ..........  ..........  ..........  ..........
                 neurostimulator.
C1779.........  Lead, pmkr,           ......  N       ..........  ..........  ..........  ..........  ..........
                 transvenous VDD.
C1780.........  Lens, intraocular     ......  N       ..........  ..........  ..........  ..........  ..........
                 (new tech).
C1781.........  Mesh (implantable)..  ......  N       ..........  ..........  ..........  ..........  ..........
C1782.........  Morcellator.........  ......  N       ..........  ..........  ..........  ..........  ..........
C1783.........  Ocular imp, aqueous   ......  N       ..........  ..........  ..........  ..........  ..........
                 drain de.
C1784.........  Ocular dev, intraop,  ......  N       ..........  ..........  ..........  ..........  ..........
                 det ret.
C1785.........  Pmkr, dual, rate-     ......  N       ..........  ..........  ..........  ..........  ..........
                 resp.
C1786.........  Pmkr, single, rate-   ......  N       ..........  ..........  ..........  ..........  ..........
                 resp.
C1787.........  Patient progr,        ......  N       ..........  ..........  ..........  ..........  ..........
                 neurostim.
C1788.........  Port, indwelling,     ......  N       ..........  ..........  ..........  ..........  ..........
                 imp.
C1789.........  Prosthesis, breast,   ......  N       ..........  ..........  ..........  ..........  ..........
                 imp.
C1813.........  Prosthesis, penile,   ......  N       ..........  ..........  ..........  ..........  ..........
                 inflatab.
C1814.........  Retinal tamp,         ......  N       ..........  ..........  ..........  ..........  ..........
                 silicone oil.
C1815.........  Pros, urinary sph,    ......  N       ..........  ..........  ..........  ..........  ..........
                 imp.
C1816.........  Receiver/             ......  N       ..........  ..........  ..........  ..........  ..........
                 transmitter, neuro.
C1817.........  Septal defect imp     ......  N       ..........  ..........  ..........  ..........  ..........
                 sys.
C1818.........  Integrated            ......  N       ..........  ..........  ..........  ..........  ..........
                 keratoprosthesis.
C1819.........  Tissue localization-  ......  N       ..........  ..........  ..........  ..........  ..........
                 excision.
C1820.........  Generator neuro       ......  H             1820  ..........  ..........  ..........  ..........
                 rechg bat sy.
C1821.........  Interspinous implant   NI...  H             1821  ..........  ..........  ..........  ..........
C1874.........  Stent, coated/cov w/  ......  N       ..........  ..........  ..........  ..........  ..........
                 del sys.
C1875.........  Stent, coated/cov w/  ......  N       ..........  ..........  ..........  ..........  ..........
                 o del sy.
C1876.........  Stent, non-coa/non-   ......  N       ..........  ..........  ..........  ..........  ..........
                 cov w/del.
C1877.........  Stent, non-coat/cov   ......  N       ..........  ..........  ..........  ..........  ..........
                 w/o del.
C1878.........  Matrl for vocal cord  ......  N       ..........  ..........  ..........  ..........  ..........
C1879.........  Tissue marker,        ......  N       ..........  ..........  ..........  ..........  ..........
                 implantable.
C1880.........  Vena cava filter....  ......  N       ..........  ..........  ..........  ..........  ..........
C1881.........  Dialysis access       ......  N       ..........  ..........  ..........  ..........  ..........
                 system.
C1882.........  AICD, other than      ......  N       ..........  ..........  ..........  ..........  ..........
                 sing/dual.
C1883.........  Adapt/ext, pacing/    ......  N       ..........  ..........  ..........  ..........  ..........
                 neuro lead.
C1884.........  Embolization Protect  ......  N       ..........  ..........  ..........  ..........  ..........
                 syst.
C1885.........  Cath, translumin      ......  N       ..........  ..........  ..........  ..........  ..........
                 angio laser.
C1887.........  Catheter, guiding...  ......  N       ..........  ..........  ..........  ..........  ..........
C1888.........  Endovas non-cardiac   ......  N       ..........  ..........  ..........  ..........  ..........
                 abl cath.
C1891.........  Infusion pump,non-    ......  N       ..........  ..........  ..........  ..........  ..........
                 prog, perm.
C1892.........  Intro/                ......  N       ..........  ..........  ..........  ..........  ..........
                 sheath,fixed,peel-
                 away.
C1893.........  Intro/sheath,         ......  N       ..........  ..........  ..........  ..........  ..........
                 fixed,non-peel.
C1894.........  Intro/sheath, non-    ......  N       ..........  ..........  ..........  ..........  ..........
                 laser.
C1895.........  Lead, AICD, endo      ......  N       ..........  ..........  ..........  ..........  ..........
                 dual coil.
C1896.........  Lead, AICD, non sing/ ......  N       ..........  ..........  ..........  ..........  ..........
                 dual.
C1897.........  Lead, neurostim test  ......  N       ..........  ..........  ..........  ..........  ..........
                 kit.
C1898.........  Lead, pmkr, other     ......  N       ..........  ..........  ..........  ..........  ..........
                 than trans.
C1899.........  Lead, pmkr/AICD       ......  N       ..........  ..........  ..........  ..........  ..........
                 combination.
C1900.........  Lead, coronary        ......  N       ..........  ..........  ..........  ..........  ..........
                 venous.
C2614.........  Probe, perc lumb      ......  N       ..........  ..........  ..........  ..........  ..........
                 disc.
C2615.........  Sealant, pulmonary,   ......  N       ..........  ..........  ..........  ..........  ..........
                 liquid.
C2616.........  Brachytx source,       CH...  K             2616    172.2337   10,586.86  ..........    2,117.37
                 Yttrium-90.
C2617.........  Stent, non-cor, tem   ......  N       ..........  ..........  ..........  ..........  ..........
                 w/o del.
C2618.........  Probe, cryoablation.  ......  N       ..........  ..........  ..........  ..........  ..........
C2619.........  Pmkr, dual, non rate- ......  N       ..........  ..........  ..........  ..........  ..........
                 resp.
C2620.........  Pmkr, single, non     ......  N       ..........  ..........  ..........  ..........  ..........
                 rate-resp.
C2621.........  Pmkr, other than      ......  N       ..........  ..........  ..........  ..........  ..........
                 sing/dual.
C2622.........  Prosthesis, penile,   ......  N       ..........  ..........  ..........  ..........  ..........
                 non-inf.
C2625.........  Stent, non-cor, tem   ......  N       ..........  ..........  ..........  ..........  ..........
                 w/del sy.
C2626.........  Infusion pump, non-   ......  N       ..........  ..........  ..........  ..........  ..........
                 prog,temp.
C2627.........  Cath, suprapubic/     ......  N       ..........  ..........  ..........  ..........  ..........
                 cystoscopic.
C2628.........  Catheter, occlusion.  ......  N       ..........  ..........  ..........  ..........  ..........
C2629.........  Intro/sheath, laser.  ......  N       ..........  ..........  ..........  ..........  ..........

[[Page 68370]]

 
C2630.........  Cath, EP, cool-tip..  ......  N       ..........  ..........  ..........  ..........  ..........
C2631.........  Rep dev, urinary, w/  ......  N       ..........  ..........  ..........  ..........  ..........
                 o sling.
C2632.........  Brachytx sol, I-125,   CH...  D       ..........  ..........  ..........  ..........  ..........
                 per mCi.
C2633.........  Brachytx source,       CH...  K             2633      1.4779       90.84  ..........       18.17
                 Cesium-131.
C2634.........  Brachytx source, HA,   CH...  K             2634      0.5316       32.68  ..........        6.54
                 I-125.
C2635.........  Brachytx source, HA,   CH...  K             2635      0.8878       54.57  ..........       10.91
                 P-103.
C2636.........  Brachytx linear        CH...  K             2636      0.6427       39.51  ..........        7.90
                 source,P-103.
C2637.........  Brachytx, Ytterbium-   CH...  B       ..........  ..........  ..........  ..........  ..........
                 169.
C8900.........  MRA w/cont, abd.....  ......  S             0284      6.1231      376.37      148.40       75.27
C8901.........  MRA w/o cont, abd...  ......  S             0336      5.6745      348.80      139.51       69.76
C8902.........  MRA w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 abd.
C8903.........  MRI w/cont, breast,   ......  S             0284      6.1231      376.37      148.40       75.27
                 uni.
C8904.........  MRI w/o cont,         ......  S             0336      5.6745      348.80      139.51       69.76
                 breast, uni.
C8905.........  MRI w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 brst, un.
C8906.........  MRI w/cont, breast,   ......  S             0284      6.1231      376.37      148.40       75.27
                 bi.
C8907.........  MRI w/o cont,         ......  S             0336      5.6745      348.80      139.51       69.76
                 breast, bi.
C8908.........  MRI w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 breast,.
C8909.........  MRA w/cont, chest...  ......  S             0284      6.1231      376.37      148.40       75.27
C8910.........  MRA w/o cont, chest.  ......  S             0336      5.6745      348.80      139.51       69.76
C8911.........  MRA w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 chest.
C8912.........  MRA w/cont, lwr ext.  ......  S             0284      6.1231      376.37      148.40       75.27
C8913.........  MRA w/o cont, lwr     ......  S             0336      5.6745      348.80      139.51       69.76
                 ext.
C8914.........  MRA w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 lwr ext.
C8918.........  MRA w/cont, pelvis..  ......  S             0284      6.1231      376.37      148.40       75.27
C8919.........  MRA w/o cont, pelvis  ......  S             0336      5.6745      348.80      139.51       69.76
C8920.........  MRA w/o fol w/cont,   ......  S             0337      8.1155      498.84      199.53       99.77
                 pelvis.
C8950.........  IV inf, tx/dx, up to   CH...  D       ..........  ..........  ..........  ..........  ..........
                 1 hr.
C8951.........  IV inf, tx/dx, each    CH...  D       ..........  ..........  ..........  ..........  ..........
                 addl hr.
C8952.........  Tx, prophy, dx IV      CH...  D       ..........  ..........  ..........  ..........  ..........
                 push.
C8953.........  Chemotx adm, IV push   CH...  D       ..........  ..........  ..........  ..........  ..........
C8954.........  Chemotx adm, IV inf    CH...  D       ..........  ..........  ..........  ..........  ..........
                 up to 1h.
C8955.........  Chemotx adm, IV inf,   CH...  D       ..........  ..........  ..........  ..........  ..........
                 addl hr.
C8957.........  Prolonged IV inf,      CH...  S             0441      2.4851      152.75  ..........       30.55
                 req pump.
C9003.........  Palivizumab, per 50   ......  K             9003  ..........      609.62  ..........      121.92
                 mg.
C9113.........  Inj pantoprazole      ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium, via.
C9121.........  Injection,            ......  K             9121  ..........       17.48  ..........        3.50
                 argatroban.
C9220.........  Sodium hyaluronate..   CH...  D       ..........  ..........  ..........  ..........  ..........
C9221.........  Graftjacket Reg        CH...  D       ..........  ..........  ..........  ..........  ..........
                 Matrix.
C9222.........  Graftjacket SftTis..   CH...  D       ..........  ..........  ..........  ..........  ..........
C9224.........  Injection,             CH...  D       ..........  ..........  ..........  ..........  ..........
                 galsulfase.
C9225.........  Fluocinolone           CH...  D       ..........  ..........  ..........  ..........  ..........
                 acetonide.
C9227.........  Injection,             CH...  D       ..........  ..........  ..........  ..........  ..........
                 micafungin sodium.
C9228.........  Injection,             CH...  D       ..........  ..........  ..........  ..........  ..........
                 tigecycline.
C9229.........  Injection              CH...  D       ..........  ..........  ..........  ..........  ..........
                 ibandronate sodium.
C9230.........  Injection, abatacept   CH...  D       ..........  ..........  ..........  ..........  ..........
C9231.........  Injection,             CH...  D       ..........  ..........  ..........  ..........  ..........
                 decitabine.
C9232.........  Injection,             NI...  G             9232  ..........      464.32  ..........       92.86
                 idursulfase.
C9233.........  Injection,             NI...  G             9233  ..........    2,067.00  ..........      413.40
                 ranibizumab.
C9234.........  Inj, alglucosidase     NI...  K             9234  ..........      127.20  ..........       25.44
                 alfa.
C9235.........  Injection,             NI...  K             9235  ..........       84.80  ..........       16.96
                 panitumumab.
C9350.........  Porous collagen tube   NI...  G             9350  ..........      494.53  ..........       98.91
                 per cm.
C9351.........  Acellular derm         NI...  G             9351  ..........       44.01  ..........        8.80
                 tissue percm2.
C9716.........  Radiofrequency         CH...  T             0150     29.6189    1,820.61      437.12      364.12
                 energy to anu.
C9723.........  Dyn IR Perf Img.....  ......  S             1502  ..........       75.00  ..........       15.00
C9724.........  EPS gast cardia plic  ......  T             0422     25.7552    1,583.12      448.81      316.62
C9725.........  Place endorectal app  ......  S             1507  ..........      550.00  ..........      110.00
C9726.........  Rxt breast appl       ......  S             1508  ..........      650.00  ..........      130.00
                 place/remov.
C9727.........  Insert palate          NI...  S             1510  ..........      850.00  ..........      170.00
                 implants.
D0150.........  Comprehensve oral     ......  S             0330       7.055      433.66  ..........       86.73
                 evaluation.
D0240.........  Intraoral occlusal    ......  S             0330       7.055      433.66  ..........       86.73
                 film.
D0250.........  Extraoral first film  ......  S             0330       7.055      433.66  ..........       86.73
D0260.........  Extraoral ea          ......  S             0330       7.055      433.66  ..........       86.73
                 additional film.
D0270.........  Dental bitewing       ......  S             0330       7.055      433.66  ..........       86.73
                 single film.
D0272.........  Dental bitewings two  ......  S             0330       7.055      433.66  ..........       86.73
                 films.
D0274.........  Dental bitewings      ......  S             0330       7.055      433.66  ..........       86.73
                 four films.
D0277.........  Vert bitewings-sev    ......  S             0330       7.055      433.66  ..........       86.73
                 to eight.
D0460.........  Pulp vitality test..  ......  S             0330       7.055      433.66  ..........       86.73
D1510.........  Space maintainer fxd  ......  S             0330       7.055      433.66  ..........       86.73
                 unilat.
D1515.........  Fixed bilat space     ......  S             0330       7.055      433.66  ..........       86.73
                 maintainer.
D1520.........  Remove unilat space   ......  S             0330       7.055      433.66  ..........       86.73
                 maintain.

[[Page 68371]]

 
D1525.........  Remove bilat space    ......  S             0330       7.055      433.66  ..........       86.73
                 maintain.
D1550.........  Recement space        ......  S             0330       7.055      433.66  ..........       86.73
                 maintainer.
D2999.........  Dental unspec         ......  S             0330       7.055      433.66  ..........       86.73
                 restorative pr.
D3460.........  Endodontic            ......  S             0330       7.055      433.66  ..........       86.73
                 endosseous implan.
D3999.........  Endodontic procedure  ......  S             0330       7.055      433.66  ..........       86.73
D4260.........  Osseous surgery per   ......  S             0330       7.055      433.66  ..........       86.73
                 quadrant.
D4263.........  Bone replce graft     ......  S             0330       7.055      433.66  ..........       86.73
                 first site.
D4264.........  Bone replce graft     ......  S             0330       7.055      433.66  ..........       86.73
                 each add.
D4268.........  Surgical revision     ......  S             0330       7.055      433.66  ..........       86.73
                 procedure.
D4270.........  Pedicle soft tissue   ......  S             0330       7.055      433.66  ..........       86.73
                 graft pr.
D4271.........  Free soft tissue      ......  S             0330       7.055      433.66  ..........       86.73
                 graft proc.
D4273.........  Subepithelial tissue  ......  S             0330       7.055      433.66  ..........       86.73
                 graft.
D4355.........  Full mouth            ......  S             0330       7.055      433.66  ..........       86.73
                 debridement.
D4381.........  Localized delivery    ......  S             0330       7.055      433.66  ..........       86.73
                 antimicro.
D5911.........  Facial moulage        ......  S             0330       7.055      433.66  ..........       86.73
                 sectional.
D5912.........  Facial moulage        ......  S             0330       7.055      433.66  ..........       86.73
                 complete.
D5983.........  Radiation applicator  ......  S             0330       7.055      433.66  ..........       86.73
D5984.........  Radiation shield....  ......  S             0330       7.055      433.66  ..........       86.73
D5985.........  Radiation cone        ......  S             0330       7.055      433.66  ..........       86.73
                 locator.
D5987.........  Commissure splint...  ......  S             0330       7.055      433.66  ..........       86.73
D6920.........  Dental connector bar  ......  S             0330       7.055      433.66  ..........       86.73
D7111.........  Extraction coronal    ......  S             0330       7.055      433.66  ..........       86.73
                 remnants.
D7140.........  Extraction erupted    ......  S             0330       7.055      433.66  ..........       86.73
                 tooth/exr.
D7210.........  Rem imp tooth w       ......  S             0330       7.055      433.66  ..........       86.73
                 mucoper flp.
D7220.........  Impact tooth remov    ......  S             0330       7.055      433.66  ..........       86.73
                 soft tiss.
D7230.........  Impact tooth remov    ......  S             0330       7.055      433.66  ..........       86.73
                 part bony.
D7240.........  Impact tooth remov    ......  S             0330       7.055      433.66  ..........       86.73
                 comp bony.
D7241.........  Impact tooth rem      ......  S             0330       7.055      433.66  ..........       86.73
                 bony w/comp.
D7250.........  Tooth root removal..  ......  S             0330       7.055      433.66  ..........       86.73
D7260.........  Oral antral fistula   ......  S             0330       7.055      433.66  ..........       86.73
                 closure.
D7261.........  Primary closure       ......  S             0330       7.055      433.66  ..........       86.73
                 sinus perf.
D7291.........  Transseptal           ......  S             0330       7.055      433.66  ..........       86.73
                 fiberotomy.
D7940.........  Reshaping bone        ......  S             0330       7.055      433.66  ..........       86.73
                 orthognathic.
D9110.........  Tx dental pain minor  ......  N       ..........  ..........  ..........  ..........  ..........
                 proc.
D9230.........  Analgesia...........  ......  N       ..........  ..........  ..........  ..........  ..........
D9248.........  Sedation (non-iv)...  ......  N       ..........  ..........  ..........  ..........  ..........
D9630.........  Other drugs/          ......  S             0330       7.055      433.66  ..........       86.73
                 medicaments.
D9930.........  Treatment of          ......  S             0330       7.055      433.66  ..........       86.73
                 complications.
D9940.........  Dental occlusal       ......  S             0330       7.055      433.66  ..........       86.73
                 guard.
D9950.........  Occlusion analysis..  ......  S             0330       7.055      433.66  ..........       86.73
D9951.........  Limited occlusal      ......  S             0330       7.055      433.66  ..........       86.73
                 adjustment.
D9952.........  Complete occlusal     ......  S             0330       7.055      433.66  ..........       86.73
                 adjustment.
E0164.........  Commode chair mobile   CH...  D       ..........  ..........  ..........  ..........  ..........
                 fixed a.
E0166.........  Commode chair mobile   CH...  D       ..........  ..........  ..........  ..........  ..........
                 detach.
E0180.........  Press pad              CH...  D       ..........  ..........  ..........  ..........  ..........
                 alternating w pump.
E0305.........  Rails bed side half    CH...  D       ..........  ..........  ..........  ..........  ..........
                 length.
E0310.........  Rails bed side full    CH...  D       ..........  ..........  ..........  ..........  ..........
                 length.
E0616.........  Cardiac event         ......  N       ..........  ..........  ..........  ..........  ..........
                 recorder.
E0676.........  Inter limb compress    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 dev NOS.
E0701.........  Helmet w face guard    CH...  D       ..........  ..........  ..........  ..........  ..........
                 prefab.
E0749.........  Elec osteogen stim    ......  N       ..........  ..........  ..........  ..........  ..........
                 implanted.
E0782.........  Non-programble        ......  N       ..........  ..........  ..........  ..........  ..........
                 infusion pump.
E0783.........  Programmable          ......  N       ..........  ..........  ..........  ..........  ..........
                 infusion pump.
E0785.........  Replacement impl      ......  N       ..........  ..........  ..........  ..........  ..........
                 pump cathet.
E0786.........  Implantable pump      ......  N       ..........  ..........  ..........  ..........  ..........
                 replacement.
E0830.........  Ambulatory traction   ......  N       ..........  ..........  ..........  ..........  ..........
                 device.
E0936.........  CPM device, other      NI...  E       ..........  ..........  ..........  ..........  ..........
                 than knee.
E0977.........  Wheelchair wedge       CH...  D       ..........  ..........  ..........  ..........  ..........
                 cushion.
E0997.........  Wheelchair caster w/   CH...  D       ..........  ..........  ..........  ..........  ..........
                 a fork.
E0998.........  Wheelchair caster w/   CH...  D       ..........  ..........  ..........  ..........  ..........
                 o a fork.
E0999.........  Wheelchr pneumatic     CH...  D       ..........  ..........  ..........  ..........  ..........
                 tire w/wh.
E1399.........  Durable medical        CH...  Y       ..........  ..........  ..........  ..........  ..........
                 equipment mi.
E2320.........  Hand chin control...   CH...  D       ..........  ..........  ..........  ..........  ..........
E2373.........  Hand/chin ctrl spec    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 joystick.
E2374.........  Hand/chin ctrl std     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 joystick.
E2375.........  Non-expandable         NI...  Y       ..........  ..........  ..........  ..........  ..........
                 controller.
E2376.........  Expandable             NI...  Y       ..........  ..........  ..........  ..........  ..........
                 controller, repl.
E2377.........  Expandable             NI...  Y       ..........  ..........  ..........  ..........  ..........
                 controller, initl.
E2381.........  Pneum drive wheel      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2382.........  Tube, pneum wheel      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 drive tire.

[[Page 68372]]

 
E2383.........  Insert, pneum wheel    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 drive.
E2384.........  Pneumatic caster       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2385.........  Tube, pneumatic        NI...  Y       ..........  ..........  ..........  ..........  ..........
                 caster tire.
E2386.........  Foam filled drive      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 wheel tire.
E2387.........  Foam filled caster     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2388.........  Foam drive wheel       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2389.........  Foam caster tire....   NI...  Y       ..........  ..........  ..........  ..........  ..........
E2390.........  Solid drive wheel      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2391.........  Solid caster tire...   NI...  Y       ..........  ..........  ..........  ..........  ..........
E2392.........  Solid caster tire,     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 integrate.
E2393.........  Valve, pneumatic       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire tube.
E2394.........  Drive wheel excludes   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 tire.
E2395.........  Caster wheel           NI...  Y       ..........  ..........  ..........  ..........  ..........
                 excludes tire.
E2396.........  Caster fork.........   NI...  Y       ..........  ..........  ..........  ..........  ..........
G0008.........  Admin influenza        CH...  S             0350      0.3945       24.25  ..........  ..........
                 virus vac.
G0009.........  Admin pneumococcal     CH...  S             0350      0.3945       24.25  ..........  ..........
                 vaccine.
G0101.........  CA screen;pelvic/      CH...  V             0604      0.8242       50.66  ..........       10.13
                 breast exam.
G0102.........  Prostate ca           ......  N       ..........  ..........  ..........  ..........  ..........
                 screening; dre.
G0104.........  CA screen;flexi       ......  S             0159      3.6592      224.92  ..........       56.23
                 sigmoidscope.
G0105.........  Colorectal scrn; hi   ......  T             0158      7.8492      446.00  ..........      111.50
                 risk ind.
G0106.........  Colon CA              ......  S             0157      2.1149      130.00  ..........       26.00
                 screen;barium enema.
G0107.........  CA screen; fecal       CH...  D       ..........  ..........  ..........  ..........  ..........
                 blood test.
G0117.........  Glaucoma scrn hgh     ......  S             0230      0.7898       48.55       14.97        9.71
                 risk direc.
G0118.........  Glaucoma scrn hgh     ......  S             0230      0.7898       48.55       14.97        9.71
                 risk direc.
G0120.........  Colon ca scrn;        ......  S             0157      2.1149      130.00  ..........       26.00
                 barium enema.
G0121.........  Colon ca scrn not hi  ......  T             0158      7.8492      446.00  ..........      111.50
                 rsk ind.
G0127.........  Trim nail(s)........  ......  T             0009      0.7744       47.60  ..........        9.52
G0129.........  Partial hosp prog     ......  P             0033      3.8188      234.73  ..........       46.95
                 service.
G0130.........  Single energy x-ray   ......  X             0260      0.7093       43.60  ..........        8.72
                 study.
G0166.........  Extrnl counterpulse,  ......  T             0678      1.7418      107.06  ..........       21.41
                 per tx.
G0173.........  Linear acc stereo      CH...  S             0067     63.3759    3,895.59  ..........      779.12
                 radsur com.
G0175.........  OPPS Service,sched     CH...  V             0608      2.1794      133.96  ..........       26.79
                 team conf.
G0176.........  OPPS/PHP;activity     ......  P             0033      3.8188      234.73  ..........       46.95
                 therapy.
G0177.........  OPPS/PHP; train &     ......  P             0033      3.8188      234.73  ..........       46.95
                 educ serv.
G0186.........  Dstry eye lesn,fdr    ......  T             0235      3.9333      241.77       58.93       48.35
                 vssl tech.
G0237.........  Therapeutic procd     ......  S             0411      0.3848       23.65  ..........        4.73
                 strg endur.
G0238.........  Oth resp proc, indiv  ......  S             0411      0.3848       23.65  ..........        4.73
G0239.........  Oth resp proc, group  ......  S             0411      0.3848       23.65  ..........        4.73
G0243.........  Multisour photon       CH...  D       ..........  ..........  ..........  ..........  ..........
                 stero treat.
G0245.........  Initial foot exam pt   CH...  V             0604      0.8242       50.66  ..........       10.13
                 lops.
G0246.........  Followup eval of       CH...  V             0605       0.984       60.48  ..........       12.10
                 foot pt lop.
G0247.........  Routine footcare pt   ......  T             0009      0.7744       47.60  ..........        9.52
                 w lops.
G0248.........  Demonstrate use home   CH...  X             0421       1.627      100.01  ..........       20.00
                 inr mon.
G0249.........  Provide test           CH...  X             0421       1.627      100.01  ..........       20.00
                 material,equipm.
G0251.........  Linear acc based       CH...  S             0065     20.3224    1,249.18  ..........      249.84
                 stero radio.
G0257.........  Unsched dialysis      ......  S             0170      6.6089      406.24  ..........       81.25
                 ESRD pt hos.
G0259.........  Inject for            ......  N       ..........  ..........  ..........  ..........  ..........
                 sacroiliac joint.
G0260.........  Inj for sacroiliac    ......  T             0206      5.7253      351.92       75.55       70.38
                 jt anesth.
G0267.........  Bone marrow or psc    ......  S             0110      3.4584      212.58  ..........       42.52
                 harvest.
G0268.........  Removal of impacted   ......  X             0340      0.6102       37.51  ..........        7.50
                 wax md.
G0269.........  Occlusive device in   ......  N       ..........  ..........  ..........  ..........  ..........
                 vein art.
G0275.........  Renal angio, cardiac  ......  N       ..........  ..........  ..........  ..........  ..........
                 cath.
G0278.........  Iliac art             ......  N       ..........  ..........  ..........  ..........  ..........
                 angio,cardiac cath.
G0288.........  Recon, CTA for surg   ......  S             0417      3.2393      199.11  ..........       39.82
                 plan.
G0289.........  Arthro, loose body +  ......  N       ..........  ..........  ..........  ..........  ..........
                 chondro.
G0290.........  Drug-eluting stents,  ......  T             0656    108.3003    6,657.00  ..........    1,331.40
                 single.
G0291.........  Drug-eluting          ......  T             0656    108.3003    6,657.00  ..........    1,331.40
                 stents,each add.
G0293.........  Non-cov surg           CH...  X             0340      0.6102       37.51  ..........        7.50
                 proc,clin trial.
G0294.........  Non-cov proc,          CH...  X             0340      0.6102       37.51  ..........        7.50
                 clinical trial.
G0297.........  Insert single         ......  T             0107    304.4894   18,716.35  ..........    3,743.27
                 chamber/cd.
G0298.........  Insert dual chamber/  ......  T             0107    304.4894   18,716.35  ..........    3,743.27
                 cd.
G0299.........  Inser/repos single    ......  T             0108    379.7339   23,341.48  ..........    4,668.30
                 icd+leads.
G0300.........  Insert reposit lead   ......  T             0108    379.7339   23,341.48  ..........    4,668.30
                 dual+gen.
G0302.........  Pre-op service LVRS   ......  S             1509  ..........      750.00  ..........      150.00
                 complete.
G0303.........  Pre-op service LVRS   ......  S             1507  ..........      550.00  ..........      110.00
                 10-15dos.
G0304.........  Pre-op service LVRS   ......  S             1504  ..........      250.00  ..........       50.00
                 1-9 dos.
G0305.........  Post op service LVRS  ......  S             1504  ..........      250.00  ..........       50.00
                 min 6.
G0332.........  Preadmin IV           ......  S             1502  ..........       75.00  ..........       15.00
                 immunoglobulin.
G0339.........  Robot lin-radsurg      CH...  S             0067     63.3759    3,895.59  ..........      779.12
                 com, first.
G0340.........  Robt lin-radsurg       CH...  S             0066     43.0297    2,644.95  ..........      528.99
                 fractx 2-5.

[[Page 68373]]

 
G0344.........  Initial preventive     CH...  V             0605       0.984       60.48  ..........       12.10
                 exam.
G0364.........  Bone marrow aspirate   CH...  T             0002      1.0995       67.58  ..........       13.52
                 &biopsy.
G0365.........  Vessel mapping hemo   ......  S             0267      2.4606      151.25       60.50       30.25
                 access.
G0367.........  EKG tracing for       ......  S             0099      0.3789       23.29  ..........        4.66
                 initial prev.
G0375.........  Smoke/tobacco          CH...  X             0031      0.1766       10.86  ..........        2.17
                 counselng 3-10.
G0376.........  Smoke/tobacco          CH...  X             0031      0.1766       10.86  ..........        2.17
                 counseling >10.
G0378.........  Hospital observation  ......  Q             0339      7.2039      442.81  ..........       88.56
                 per hr.
G0379.........  Direct admit           CH...  Q             0604      0.8242       50.66  ..........       10.13
                 hospital observ.
G0380.........  Lev 1 hosp type B ED   NF...  V             0604      0.8242       50.66  ..........       10.13
                 visit.
G0381.........  Lev 2 hosp type B ED   NF...  V             0605       0.984       60.48  ..........       12.10
                 visit.
G0382.........  Lev 3 hosp type B ED   NF...  V             0606      1.3646       83.88  ..........       16.78
                 visit.
G0383.........  Lev 4 hosp type B ED   NF...  V             0607      1.7096      105.09  ..........       21.02
                 visit.
G0384.........  Lev 5 hosp type B ED   NF...  V             0608      2.1794      133.96  ..........       26.79
                 visit.
G0389.........  Ultrasound exam AAA    NI...  S             0266      1.5607       95.93       37.80       19.19
                 screen.
G0390.........  Trauma respon w/hosp   NI...  S             0618      8.0455      494.54      197.81       98.91
                 cirtica.
G0392.........  AV fistula or graft    NI...  T             0081      42.936    2,639.19  ..........      527.84
                 arterial.
G0393.........  AV fistula or graft    NI...  T             0081      42.936    2,639.19  ..........      527.84
                 venous.
G0394.........  Blood occult test,     NI...  A       ..........  ..........  ..........  ..........  ..........
                 colorecta.
G3001.........  Admin + supply,        CH...  S             0442     22.3666    1,374.83  ..........      274.97
                 tositumomab.
G8085.........  ESRD pt inelig         NI...  M       ..........  ..........  ..........  ..........  ..........
                 autogenous Fi.
J0120.........  Tetracyclin           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0128.........  Abarelix injection..   CH...  K             9216  ..........       71.18  ..........       14.24
J0129.........  Abatacept injection.   NI...  G             9230  ..........       18.70  ..........        3.74
J0130.........  Abciximab injection.  ......  K             1605  ..........      416.27  ..........       83.25
J0132.........  Acetylcysteine        ......  K             1680  ..........        1.94  ..........        0.39
                 injection.
J0133.........  Acyclovir injection.  ......  N       ..........  ..........  ..........  ..........  ..........
J0135.........  Adalimumab injection  ......  K             1083  ..........      308.33  ..........       61.67
J0150.........  Injection adenosine   ......  K             0379  ..........       30.49  ..........        6.10
                 6 MG.
J0152.........  Adenosine injection.  ......  K             0917  ..........       30.49  ..........        6.10
J0170.........  Adrenalin epinephrin  ......  N       ..........  ..........  ..........  ..........  ..........
                 inject.
J0180.........  Agalsidase beta       ......  K             9208  ..........      127.20  ..........       25.44
                 injection.
J0190.........  Inj biperiden          CH...  K             3038  ..........       88.15  ..........       17.63
                 lactate/5 mg.
J0200.........  Alatrofloxacin        ......  N       ..........  ..........  ..........  ..........  ..........
                 mesylate.
J0205.........  Alglucerase           ......  K             0900  ..........       39.22  ..........        7.84
                 injection.
J0207.........  Amifostine..........  ......  K             7000  ..........      463.27  ..........       92.65
J0210.........  Methyldopate hcl      ......  K             2210  ..........       10.01  ..........        2.00
                 injection.
J0215.........  Alefacept...........  ......  K             1633  ..........       26.31  ..........        5.26
J0256.........  Alpha 1 proteinase    ......  K             0901  ..........        3.31  ..........        0.66
                 inhibitor.
J0278.........  Amikacin sulfate       CH...  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0280.........  Aminophyllin 250 MG   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J0282.........  Amiodarone HCl......  ......  N       ..........  ..........  ..........  ..........  ..........
J0285.........  Amphotericin B......   CH...  N       ..........  ..........  ..........  ..........  ..........
J0287.........  Amphotericin b lipid  ......  K             9024  ..........       11.11  ..........        2.22
                 complex.
J0288.........  Ampho b cholesteryl   ......  K             0735  ..........       12.00  ..........        2.40
                 sulfate.
J0289.........  Amphotericin b        ......  K             0736  ..........       21.25  ..........        4.25
                 liposome inj.
J0290.........  Ampicillin 500 MG     ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J0295.........  Ampicillin sodium     ......  N       ..........  ..........  ..........  ..........  ..........
                 per 1.5 gm.
J0300.........  Amobarbital 125 MG    ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J0330.........  Succinycholine        ......  N       ..........  ..........  ..........  ..........  ..........
                 chloride inj.
J0348.........  Anadulafungin          NI...  G             0760  ..........        1.91  ..........        0.38
                 injection.
J0350.........  Injection             ......  K             1606  ..........    2,268.46  ..........      453.69
                 anistreplase 30 u.
J0360.........  Hydralazine hcl       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0364.........  Apomorphine            NI...  K             0766  ..........        2.92  ..........        0.58
                 hydrochloride.
J0365.........  Aprotonin, 10,000     ......  K             1682  ..........        2.52  ..........        0.50
                 kiu.
J0380.........  Inj metaraminol        CH...  K             3039  ..........        2.62  ..........        0.52
                 bitartrate.
J0390.........  Chloroquine           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0395.........  Arbutamine HCl        ......  K             9031  ..........      160.00  ..........       32.00
                 injection.
J0456.........  Azithromycin........  ......  N       ..........  ..........  ..........  ..........  ..........
J0460.........  Atropine sulfate      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0470.........  Dimecaprol injection   CH...  N       ..........  ..........  ..........  ..........  ..........
J0475.........  Baclofen 10 MG        ......  K             9032  ..........      198.54  ..........       39.71
                 injection.
J0476.........  Baclofen intrathecal  ......  K             1631  ..........       69.63  ..........       13.93
                 trial.
J0480.........  Basiliximab.........  ......  K             1683  ..........    1,385.86  ..........      277.17
J0500.........  Dicyclomine           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0515.........  Inj benztropine       ......  N       ..........  ..........  ..........  ..........  ..........
                 mesylate.
J0520.........  Bethanechol chloride  ......  N       ..........  ..........  ..........  ..........  ..........
                 inject.
J0530.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.
J0540.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.
J0550.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.
J0560.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.

[[Page 68374]]

 
J0570.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.
J0580.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 benzathine inj.
J0583.........  Bivalirudin.........   CH...  K             3041  ..........        1.75  ..........        0.35
J0585.........  Botulinum toxin a     ......  K             0902  ..........        5.04  ..........        1.01
                 per unit.
J0587.........  Botulinum toxin type  ......  K             9018  ..........        8.16  ..........        1.63
                 B.
J0592.........  Buprenorphine         ......  N       ..........  ..........  ..........  ..........  ..........
                 hydrochloride.
J0594.........  Busulfan injection..   NI...  K             1178  ..........        8.89  ..........        1.78
J0595.........  Butorphanol tartrate  ......  N       ..........  ..........  ..........  ..........  ..........
                 1 mg.
J0600.........  Edetate calcium       ......  K             0892  ..........       40.19  ..........        8.04
                 disodium inj.
J0610.........  Calcium gluconate     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0620.........  Calcium glycer &      ......  N       ..........  ..........  ..........  ..........  ..........
                 lact/10 ML.
J0630.........  Calcitonin salmon      CH...  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0636.........  Inj calcitriol per    ......  N       ..........  ..........  ..........  ..........  ..........
                 0.1 mcg.
J0637.........  Caspofungin acetate.  ......  K             9019  ..........       32.25  ..........        6.45
J0640.........  Leucovorin calcium    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0670.........  Inj mepivacaine HCL/  ......  N       ..........  ..........  ..........  ..........  ..........
                 10 ml.
J0690.........  Cefazolin sodium      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0692.........  Cefepime HCl for      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0694.........  Cefoxitin sodium      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0696.........  Ceftriaxone sodium    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0697.........  Sterile cefuroxime    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0698.........  Cefotaxime sodium     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0702.........  Betamethasone         ......  N       ..........  ..........  ..........  ..........  ..........
                 acet&sod phosp.
J0704.........  Betamethasone sod     ......  N       ..........  ..........  ..........  ..........  ..........
                 phosp/4 MG.
J0706.........  Caffeine citrate      ......  K             0876  ..........        3.54  ..........        0.71
                 injection.
J0710.........  Cephapirin sodium     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0713.........  Inj ceftazidime per   ......  N       ..........  ..........  ..........  ..........  ..........
                 500 mg.
J0715.........  Ceftizoxime sodium /  ......  N       ..........  ..........  ..........  ..........  ..........
                 500 MG.
J0720.........  Chloramphenicol       ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium injec.
J0725.........  Chorionic             ......  N       ..........  ..........  ..........  ..........  ..........
                 gonadotropin/1000u.
J0735.........  Clonidine             ......  K             0935  ..........       66.04  ..........       13.21
                 hydrochloride.
J0740.........  Cidofovir injection.  ......  K             9033  ..........      763.15  ..........      152.63
J0743.........  Cilastatin sodium     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0744.........  Ciprofloxacin iv....  ......  N       ..........  ..........  ..........  ..........  ..........
J0745.........  Inj codeine           ......  N       ..........  ..........  ..........  ..........  ..........
                 phosphate /30 MG.
J0760.........  Colchicine injection  ......  N       ..........  ..........  ..........  ..........  ..........
J0770.........  Colistimethate        ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium inj.
J0780.........  Prochlorperazine      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J0795.........  Corticorelin ovine    ......  K             1684  ..........        4.17  ..........        0.83
                 triflutal.
J0800.........  Corticotropin         ......  K             1280  ..........      116.60  ..........       23.32
                 injection.
J0835.........  Inj cosyntropin per   ......  K             0835  ..........       62.91  ..........       12.58
                 0.25 MG.
J0850.........  Cytomegalovirus imm   ......  K             0903  ..........      853.18  ..........      170.64
                 IV /vial.
J0878.........  Daptomycin injection   CH...  K             9124  ..........        0.33  ..........        0.07
J0881.........  Darbepoetin alfa,     ......  K             1685  ..........        2.99  ..........        0.60
                 non-esrd.
J0882.........  Darbepoetin alfa,      CH...  A       ..........  ..........  ..........  ..........  ..........
                 esrd use.
J0885.........  Epoetin alfa, non-    ......  K             1686  ..........        9.36  ..........        1.87
                 esrd.
J0886.........  Epoetin alfa 1000      CH...  A       ..........  ..........  ..........  ..........  ..........
                 units ESRD.
J0894.........  Decitabine injection   NI...  G             9231  ..........       26.50  ..........        5.30
J0895.........  Deferoxamine          ......  K             0895  ..........       14.84  ..........        2.97
                 mesylate inj.
J0900.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 enanthate inj.
J0945.........  Brompheniramine       ......  N       ..........  ..........  ..........  ..........  ..........
                 maleate inj.
J0970.........  Estradiol valerate    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1000.........  Depo-estradiol        ......  N       ..........  ..........  ..........  ..........  ..........
                 cypionate inj.
J1020.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 20 MG inj.
J1030.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 40 MG inj.
J1040.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 80 MG inj.
J1051.........  Medroxyprogesterone   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J1060.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 cypionate 1 ML.
J1070.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 cypionat 100 MG.
J1080.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 cypionat 200 MG.
J1094.........  Inj dexamethasone     ......  N       ..........  ..........  ..........  ..........  ..........
                 acetate.
J1100.........  Dexamethasone sodium  ......  N       ..........  ..........  ..........  ..........  ..........
                 phos.
J1110.........  Inj                    CH...  N       ..........  ..........  ..........  ..........  ..........
                 dihydroergotamine
                 mesylt.
J1120.........  Acetazolamid sodium   ......  N       ..........  ..........  ..........  ..........  ..........
                 injectio.
J1160.........  Digoxin injection...  ......  N       ..........  ..........  ..........  ..........  ..........
J1162.........  Digoxin immune fab    ......  K             1687  ..........      533.72  ..........      106.74
                 (ovine).
J1165.........  Phenytoin sodium      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1170.........  Hydromorphone         ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1180.........  Dyphylline injection   CH...  N       ..........  ..........  ..........  ..........  ..........
J1190.........  Dexrazoxane HCl       ......  K             0726  ..........      180.13  ..........       36.03
                 injection.

[[Page 68375]]

 
J1200.........  Diphenhydramine hcl   ......  N       ..........  ..........  ..........  ..........  ..........
                 injectio.
J1205.........  Chlorothiazide         CH...  K             0747  ..........      123.84  ..........       24.77
                 sodium inj.
J1212.........  Dimethyl sulfoxide    ......  N       ..........  ..........  ..........  ..........  ..........
                 50% 50 ML.
J1230.........  Methadone injection.  ......  N       ..........  ..........  ..........  ..........  ..........
J1240.........  Dimenhydrinate        ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1245.........  Dipyridamole          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1250.........  Inj dobutamine HCL/   ......  N       ..........  ..........  ..........  ..........  ..........
                 250 mg.
J1260.........  Dolasetron mesylate.  ......  K             0750  ..........        6.89  ..........        1.38
J1265.........  Dopamine injection..  ......  N       ..........  ..........  ..........  ..........  ..........
J1270.........  Injection,            ......  N       ..........  ..........  ..........  ..........  ..........
                 doxercalciferol.
J1320.........  Amitriptyline         ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1324.........  Enfuvirtide            NI...  K             0767  ..........       21.82  ..........        4.36
                 injection.
J1325.........  Epoprostenol          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1327.........  Eptifibatide          ......  K             1607  ..........       15.37  ..........        3.07
                 injection.
J1330.........  Ergonovine maleate    ......  K             1330  ..........       33.11  ..........        6.62
                 injection.
J1335.........  Ertapenem injection.  ......  N       ..........  ..........  ..........  ..........  ..........
J1364.........  Erythro lactobionate  ......  N       ..........  ..........  ..........  ..........  ..........
                 /500 MG.
J1380.........  Estradiol valerate    ......  N       ..........  ..........  ..........  ..........  ..........
                 10 MG inj.
J1390.........  Estradiol valerate    ......  N       ..........  ..........  ..........  ..........  ..........
                 20 MG inj.
J1410.........  Inj estrogen          ......  K             9038  ..........       58.05  ..........       11.61
                 conjugate 25 MG.
J1430.........  Ethanolamine oleate   ......  K             1688  ..........       69.60  ..........       13.92
                 100 mg.
J1435.........  Injection estrone     ......  N       ..........  ..........  ..........  ..........  ..........
                 per 1 MG.
J1436.........  Etidronate disodium   ......  K             1436  ..........       71.41  ..........       14.28
                 inj.
J1438.........  Etanercept injection  ......  K             1608  ..........      160.39  ..........       32.08
J1440.........  Filgrastim 300 mcg    ......  K             0728  ..........      188.07  ..........       37.61
                 injection.
J1441.........  Filgrastim 480 mcg    ......  K             7049  ..........      298.70  ..........       59.74
                 injection.
J1450.........  Fluconazole.........  ......  N       ..........  ..........  ..........  ..........  ..........
J1451.........  Fomepizole, 15 mg...  ......  K             1689  ..........       12.33  ..........        2.47
J1452.........  Intraocular           ......  K             9040  ..........      212.00  ..........       42.40
                 Fomivirsen na.
J1455.........  Foscarnet sodium       CH...  K             3042  ..........       10.49  ..........        2.10
                 injection.
J1457.........  Gallium nitrate        CH...  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1458.........  Galsulfase injection   NI...  K             9224  ..........    1,516.12  ..........      303.22
J1460.........  Gamma globulin 1 CC    CH...  K             3043  ..........       10.34  ..........        2.07
                 inj.
J1562.........  Immune globulin        NI...  K             0804  ..........        7.08  ..........        1.42
                 subcutaneous.
J1565.........  RSV-ivig............  ......  K             0906  ..........       16.18  ..........        3.24
J1566.........  Immune globulin,      ......  K             2731  ..........       25.27  ..........        5.05
                 powder.
J1567.........  Immune globulin,      ......  K             2732  ..........       30.33  ..........        6.07
                 liquid.
J1570.........  Ganciclovir sodium    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1580.........  Garamycin gentamicin  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J1590.........  Gatifloxacin          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1595.........  Injection glatiramer  ......  N       ..........  ..........  ..........  ..........  ..........
                 acetate.
J1600.........  Gold sodium           ......  N       ..........  ..........  ..........  ..........  ..........
                 thiomaleate inj.
J1610.........  Glucagon              ......  K             9042  ..........       70.23  ..........       14.05
                 hydrochloride/1 MG.
J1620.........  Gonadorelin hydroch/  ......  K             7005  ..........      189.84  ..........       37.97
                 100 mcg.
J1626.........  Granisetron HCl       ......  K             0764  ..........        7.21  ..........        1.44
                 injection.
J1630.........  Haloperidol           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1631.........  Haloperidol           ......  N       ..........  ..........  ..........  ..........  ..........
                 decanoate inj.
J1640.........  Hemin, 1 mg.........  ......  K             1690  ..........        6.80  ..........        1.36
J1642.........  Inj heparin sodium    ......  N       ..........  ..........  ..........  ..........  ..........
                 per 10 u.
J1644.........  Inj heparin sodium    ......  N       ..........  ..........  ..........  ..........  ..........
                 per 1000u.
J1645.........  Dalteparin sodium...  ......  N       ..........  ..........  ..........  ..........  ..........
J1650.........  Inj enoxaparin        ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium.
J1652.........  Fondaparinux sodium.  ......  N       ..........  ..........  ..........  ..........  ..........
J1655.........  Tinzaparin sodium     ......  K             1655  ..........        2.48  ..........        0.50
                 injection.
J1670.........  Tetanus immune        ......  K             1670  ..........       87.77  ..........       17.55
                 globulin inj.
J1700.........  Hydrocortisone        ......  N       ..........  ..........  ..........  ..........  ..........
                 acetate inj.
J1710.........  Hydrocortisone        ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium ph inj.
J1720.........  Hydrocortisone        ......  N       ..........  ..........  ..........  ..........  ..........
                 sodium succ i.
J1730.........  Diazoxide injection.  ......  K             1740  ..........      111.89  ..........       22.38
J1740.........  Ibandronate sodium     NI...  G             9229  ..........      139.12  ..........       27.82
                 injection.
J1742.........  Ibutilide fumarate    ......  K             9044  ..........      265.75  ..........       53.15
                 injection.
J1745.........  Infliximab injection  ......  K             7043  ..........       53.74  ..........       10.75
J1751.........  Iron dextran 165      ......  K             1691  ..........       11.78  ..........        2.36
                 injection.
J1752.........  Iron dextran 267      ......  K             1692  ..........       10.38  ..........        2.08
                 injection.
J1756.........  Iron sucrose          ......  K             9046  ..........        0.36  ..........        0.07
                 injection.
J1785.........  Injection             ......  K             0916  ..........        3.91  ..........        0.78
                 imiglucerase /unit.
J1790.........  Droperidol injection  ......  N       ..........  ..........  ..........  ..........  ..........
J1800.........  Propranolol           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1815.........  Insulin injection...  ......  N       ..........  ..........  ..........  ..........  ..........
J1817.........  Insulin for insulin   ......  N       ..........  ..........  ..........  ..........  ..........
                 pump use.

[[Page 68376]]

 
J1830.........  Interferon beta-1b /  ......  K             0910  ..........       90.00  ..........       18.00
                 .25 MG.
J1835.........  Itraconazole          ......  K             9047  ..........       36.45  ..........        7.29
                 injection.
J1840.........  Kanamycin sulfate     ......  N       ..........  ..........  ..........  ..........  ..........
                 500 MG inj.
J1850.........  Kanamycin sulfate 75  ......  N       ..........  ..........  ..........  ..........  ..........
                 MG inj.
J1885.........  Ketorolac             ......  N       ..........  ..........  ..........  ..........  ..........
                 tromethamine inj.
J1890.........  Cephalothin sodium    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1931.........  Laronidase injection  ......  K             9209  ..........       23.87  ..........        4.77
J1940.........  Furosemide injection  ......  N       ..........  ..........  ..........  ..........  ..........
J1945.........  Lepirudin...........  ......  K             1693  ..........      153.54  ..........       30.71
J1950.........  Leuprolide acetate /  ......  K             0800  ..........      437.58  ..........       87.52
                 3.75 MG.
J1956.........  Levofloxacin          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J1960.........  Levorphanol tartrate  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J1980.........  Hyoscyamine sulfate   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J1990.........  Chlordiazepoxide      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2001.........  Lidocaine injection.  ......  N       ..........  ..........  ..........  ..........  ..........
J2010.........  Lincomycin injection  ......  N       ..........  ..........  ..........  ..........  ..........
J2020.........  Linezolid injection.  ......  K             9001  ..........       24.16  ..........        4.83
J2060.........  Lorazepam injection.  ......  N       ..........  ..........  ..........  ..........  ..........
J2150.........  Mannitol injection..  ......  N       ..........  ..........  ..........  ..........  ..........
J2170.........  Mecasermin injection   NI...  K             0805  ..........       11.93  ..........        2.39
J2175.........  Meperidine hydrochl / ......  N       ..........  ..........  ..........  ..........  ..........
                 100 MG.
J2180.........  Meperidine/           ......  N       ..........  ..........  ..........  ..........  ..........
                 promethazine inj.
J2185.........  Meropenem...........   CH...  K             3045  ..........        3.68  ..........        0.74
J2210.........  Methylergonovin       ......  N       ..........  ..........  ..........  ..........  ..........
                 maleate inj.
J2248.........  Micafungin sodium      NI...  G             9227  ..........        1.87  ..........        0.37
                 injection.
J2250.........  Inj midazolam         ......  N       ..........  ..........  ..........  ..........  ..........
                 hydrochloride.
J2260.........  Inj milrinone         ......  N       ..........  ..........  ..........  ..........  ..........
                 lactate / 5 MG.
J2270.........  Morphine sulfate      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2271.........  Morphine so4          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection 100mg.
J2275.........  Morphine sulfate      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2278.........  Ziconotide injection  ......  G             1694  ..........        6.34  ..........        1.27
J2280.........  Inj, moxifloxacin     ......  N       ..........  ..........  ..........  ..........  ..........
                 100 mg.
J2300.........  Inj nalbuphine        ......  N       ..........  ..........  ..........  ..........  ..........
                 hydrochloride.
J2310.........  Inj naloxone          ......  N       ..........  ..........  ..........  ..........  ..........
                 hydrochloride.
J2315.........  Naltrexone, depot      NI...  K             0759  ..........        1.94  ..........        0.39
                 form.
J2320.........  Nandrolone decanoate  ......  N       ..........  ..........  ..........  ..........  ..........
                 50 MG.
J2321.........  Nandrolone decanoate  ......  N       ..........  ..........  ..........  ..........  ..........
                 100 MG.
J2322.........  Nandrolone decanoate  ......  N       ..........  ..........  ..........  ..........  ..........
                 200 MG.
J2325.........  Nesiritide injection  ......  K             1695  ..........       30.13  ..........        6.03
J2353.........  Octreotide            ......  K             1207  ..........       93.35  ..........       18.67
                 injection, depot.
J2354.........  Octreotide inj, non-  ......  N       ..........  ..........  ..........  ..........  ..........
                 depot.
J2355.........  Oprelvekin injection  ......  K             7011  ..........      245.98  ..........       49.20
J2357.........  Omalizumab injection   CH...  K             9300  ..........       16.61  ..........        3.32
J2360.........  Orphenadrine          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2370.........  Phenylephrine hcl     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2400.........  Chloroprocaine hcl    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2405.........  Ondansetron hcl       ......  K             0768  ..........        3.72  ..........        0.74
                 injection.
J2410.........  Oxymorphone hcl       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2425.........  Palifermin injection  ......  K             1696  ..........       11.43  ..........        2.29
J2430.........  Pamidronate disodium  ......  K             0730  ..........       34.80  ..........        6.96
                 /30 MG.
J2440.........  Papaverin hcl         ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2460.........  Oxytetracycline       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2469.........  Palonosetron HCl....  ......  K             9210  ..........       18.08  ..........        3.62
J2501.........  Paricalcitol........  ......  N       ..........  ..........  ..........  ..........  ..........
J2503.........  Pegaptanib sodium     ......  G             1697  ..........    1,107.54  ..........      221.51
                 injection.
J2504.........  Pegademase bovine,    ......  K             1739  ..........      177.83  ..........       35.57
                 25 iu.
J2505.........  Injection,            ......  K             9119  ..........    2,163.61  ..........      432.72
                 pegfilgrastim 6mg.
J2510.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 procaine inj.
J2513.........  Pentastarch 10%        CH...  N       ..........  ..........  ..........  ..........  ..........
                 solution.
J2515.........  Pentobarbital sodium  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J2540.........  Penicillin g          ......  N       ..........  ..........  ..........  ..........  ..........
                 potassium inj.
J2543.........  Piperacillin/         ......  N       ..........  ..........  ..........  ..........  ..........
                 tazobactam.
J2550.........  Promethazine hcl      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2560.........  Phenobarbital sodium  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J2590.........  Oxytocin injection..  ......  N       ..........  ..........  ..........  ..........  ..........
J2597.........  Inj desmopressin      ......  N       ..........  ..........  ..........  ..........  ..........
                 acetate.
J2650.........  Prednisolone acetate  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J2670.........  Totazoline hcl        ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2675.........  Inj progesterone per  ......  N       ..........  ..........  ..........  ..........  ..........
                 50 MG.
J2680.........  Fluphenazine          ......  N       ..........  ..........  ..........  ..........  ..........
                 decanoate 25 MG.

[[Page 68377]]

 
J2690.........  Procainamide hcl      ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2700.........  Oxacillin sodium       CH...  N       ..........  ..........  ..........  ..........  ..........
                 injeciton.
J2710.........  Neostigmine           ......  N       ..........  ..........  ..........  ..........  ..........
                 methylslfte inj.
J2720.........  Inj protamine         ......  N       ..........  ..........  ..........  ..........  ..........
                 sulfate/10 MG.
J2725.........  Inj protirelin per    ......  N       ..........  ..........  ..........  ..........  ..........
                 250 mcg.
J2730.........  Pralidoxime chloride   CH...  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J2760.........  Phentolaine mesylate  ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J2765.........  Metoclopramide hcl    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2770.........  Quinupristin/         ......  K             2770  ..........      114.49  ..........       22.90
                 dalfopristin.
J2780.........  Ranitidine            ......  N       ..........  ..........  ..........  ..........  ..........
                 hydrochloride inj.
J2783.........  Rasburicase.........   CH...  K             0738  ..........      121.26  ..........       24.25
J2788.........  Rho d immune          ......  K             9023  ..........       27.70  ..........        5.54
                 globulin 50 mcg.
J2790.........  Rho d immune          ......  K             0884  ..........       80.52  ..........       16.10
                 globulin inj.
J2792.........  Rho(D) immune         ......  K             1609  ..........       14.30  ..........        2.86
                 globulin h, sd.
J2794.........  Risperidone, long      CH...  K             9125  ..........        4.80  ..........        0.96
                 acting.
J2795.........  Ropivacaine HCl       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2800.........  Methocarbamol         ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2805.........  Sincalide injection.   CH...  N       ..........  ..........  ..........  ..........  ..........
J2810.........  Inj theophylline per  ......  N       ..........  ..........  ..........  ..........  ..........
                 40 MG.
J2820.........  Sargramostim          ......  K             0731  ..........       25.55  ..........        5.11
                 injection.
J2850.........  Inj secretin          ......  K             1700  ..........       20.31  ..........        4.06
                 synthetic human.
J2910.........  Aurothioglucose        CH...  N       ..........  ..........  ..........  ..........  ..........
                 injeciton.
J2912.........  Sodium chloride        CH...  D       ..........  ..........  ..........  ..........  ..........
                 injection.
J2916.........  Na ferric gluconate   ......  N       ..........  ..........  ..........  ..........  ..........
                 complex.
J2920.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2930.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2940.........  Somatrem injection..  ......  K             2940  ..........       35.60  ..........        7.12
J2941.........  Somatropin injection  ......  K             7034  ..........       46.80  ..........        9.36
J2950.........  Promazine hcl         ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J2993.........  Reteplase injection.  ......  K             9005  ..........      902.72  ..........      180.54
J2995.........  Inj streptokinase /   ......  K             0911  ..........       79.50  ..........       15.90
                 250000 IU.
J2997.........  Alteplase             ......  K             7048  ..........       32.07  ..........        6.41
                 recombinant.
J3000.........  Streptomycin          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3010.........  Fentanyl citrate      ......  N       ..........  ..........  ..........  ..........  ..........
                 injeciton.
J3030.........  Sumatriptan           ......  K             3030  ..........       57.40  ..........       11.48
                 succinate / 6 MG.
J3070.........  Pentazocine           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3100.........  Tenecteplase          ......  K             9002  ..........    2,036.66  ..........      407.33
                 injection.
J3105.........  Terbutaline sulfate   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J3120.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 enanthate inj.
J3130.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 enanthate inj.
J3140.........  Testosterone          ......  N       ..........  ..........  ..........  ..........  ..........
                 suspension inj.
J3150.........  Testosteron           ......  N       ..........  ..........  ..........  ..........  ..........
                 propionate inj.
J3230.........  Chlorpromazine hcl    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3240.........  Thyrotropin           ......  K             9108  ..........      765.76  ..........      153.15
                 injection.
J3243.........  Tigecycline            NI...  G             9228  ..........        0.91  ..........        0.18
                 injection.
J3246.........  Tirofiban HCl.......  ......  K             7041  ..........        8.74  ..........        1.75
J3250.........  Trimethobenzamide     ......  N       ..........  ..........  ..........  ..........  ..........
                 hcl inj.
J3260.........  Tobramycin sulfate    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3265.........  Injection torsemide   ......  N       ..........  ..........  ..........  ..........  ..........
                 10 mg/ml.
J3280.........  Thiethylperazine      ......  N       ..........  ..........  ..........  ..........  ..........
                 maleate inj.
J3285.........  Treprostinil          ......  K             1701  ..........       54.02  ..........       10.80
                 injection.
J3301.........  Triamcinolone         ......  N       ..........  ..........  ..........  ..........  ..........
                 acetonide inj.
J3302.........  Triamcinolone         ......  N       ..........  ..........  ..........  ..........  ..........
                 diacetate inj.
J3303.........  Triamcinolone         ......  N       ..........  ..........  ..........  ..........  ..........
                 hexacetonl inj.
J3305.........  Inj trimetrexate      ......  K             7045  ..........      145.17  ..........       29.03
                 glucoronate.
J3310.........  Perphenazine          ......  N       ..........  ..........  ..........  ..........  ..........
                 injeciton.
J3315.........  Triptorelin pamoate.  ......  K             9122  ..........      218.53  ..........       43.71
J3320.........  Spectinomycn di-hcl    CH...  K             0753  ..........       30.08  ..........        6.02
                 inj.
J3350.........  Urea injection......  ......  K             9051  ..........       37.81  ..........        7.56
J3355.........  Urofollitropin, 75    ......  K             1741  ..........       49.35  ..........        9.87
                 iu.
J3360.........  Diazepam injection..  ......  N       ..........  ..........  ..........  ..........  ..........
J3364.........  Urokinase 5000 IU     ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3365.........  Urokinase 250,000 IU  ......  K             7036  ..........      457.73  ..........       91.55
                 inj.
J3370.........  Vancomycin hcl        ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3396.........  Verteporfin           ......  K             1203  ..........        8.91  ..........        1.78
                 injection.
J3400.........  Triflupromazine hcl   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J3410.........  Hydroxyzine hcl       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3411.........  Thiamine hcl 100 mg.  ......  N       ..........  ..........  ..........  ..........  ..........
J3415.........  Pyridoxine hcl 100    ......  N       ..........  ..........  ..........  ..........  ..........
                 mg.
J3420.........  Vitamin b12           ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.

[[Page 68378]]

 
J3430.........  Vitamin k             ......  N       ..........  ..........  ..........  ..........  ..........
                 phytonadione inj.
J3465.........  Injection,            ......  K             1052  ..........        4.66  ..........        0.93
                 voriconazole.
J3470.........  Hyaluronidase          CH...  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3471.........  Ovine, up to 999 USP   CH...  N       ..........  ..........  ..........  ..........  ..........
                 units.
J3472.........  Ovine, 1000 USP       ......  K             1703  ..........      137.43  ..........       27.49
                 units.
J3473.........  Hyaluronidase          NI...  G             0806  ..........        0.40  ..........        0.08
                 recombinant.
J3475.........  Inj magnesium         ......  N       ..........  ..........  ..........  ..........  ..........
                 sulfate.
J3480.........  Inj potassium         ......  N       ..........  ..........  ..........  ..........  ..........
                 chloride.
J3485.........  Zidovudine..........  ......  N       ..........  ..........  ..........  ..........  ..........
J3486.........  Ziprasidone mesylate  ......  N       ..........  ..........  ..........  ..........  ..........
J3487.........  Zoledronic acid.....  ......  K             9115  ..........      204.03  ..........       40.81
J3490.........  Drugs unclassified    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J3530.........  Nasal vaccine         ......  N       ..........  ..........  ..........  ..........  ..........
                 inhalation.
J3590.........  Unclassified          ......  N       ..........  ..........  ..........  ..........  ..........
                 biologics.
J7030.........  Normal saline         ......  N       ..........  ..........  ..........  ..........  ..........
                 solution infus.
J7040.........  Normal saline         ......  N       ..........  ..........  ..........  ..........  ..........
                 solution infus.
J7042.........  5% dextrose/normal    ......  N       ..........  ..........  ..........  ..........  ..........
                 saline.
J7050.........  Normal saline         ......  N       ..........  ..........  ..........  ..........  ..........
                 solution infus.
J7060.........  5% dextrose/water...  ......  N       ..........  ..........  ..........  ..........  ..........
J7070.........  D5w infusion........  ......  N       ..........  ..........  ..........  ..........  ..........
J7100.........  Dextran 40 infusion.  ......  N       ..........  ..........  ..........  ..........  ..........
J7110.........  Dextran 75 infusion.  ......  N       ..........  ..........  ..........  ..........  ..........
J7120.........  Ringers lactate       ......  N       ..........  ..........  ..........  ..........  ..........
                 infusion.
J7130.........  Hypertonic saline     ......  N       ..........  ..........  ..........  ..........  ..........
                 solution.
J7187.........  Inj Vonwillebrand      NI...  K             1704  ..........        0.88  ..........        0.18
                 factor IU.
J7188.........  Inj Vonwillebrand      CH...  D       ..........  ..........  ..........  ..........  ..........
                 factor iu.
J7189.........  Factor viia.........  ......  K             1705  ..........        1.10  ..........        0.22
J7190.........  Factor viii.........  ......  K             0925  ..........        0.69  ..........        0.14
J7191.........  Factor VIII           ......  K             0926  ..........        1.33  ..........        0.27
                 (porcine).
J7192.........  Factor viii           ......  K             0927  ..........        1.06  ..........        0.21
                 recombinant.
J7193.........  Factor IX non-        ......  K             0931  ..........        0.90  ..........        0.18
                 recombinant.
J7194.........  Factor ix complex...  ......  K             0928  ..........        0.72  ..........        0.14
J7195.........  Factor IX             ......  K             0932  ..........        0.99  ..........        0.20
                 recombinant.
J7197.........  Antithrombin iii      ......  K             0930  ..........        1.62  ..........        0.32
                 injection.
J7198.........  Anti-inhibitor......  ......  K             0929  ..........        1.36  ..........        0.27
J7308.........  Aminolevulinic acid   ......  K             7308  ..........      107.72  ..........       21.54
                 hcl top.
J7310.........  Ganciclovir long act  ......  K             0913  ..........    4,766.14  ..........      953.23
                 implant.
J7311.........  Fluocinolone           NI...  G             9225  ..........   18,250.00  ..........    3,650.00
                 acetonide implt.
J7317.........  Sodium hyaluronate     CH...  D       ..........  ..........  ..........  ..........  ..........
                 injection.
J7319.........  Sodium Hyaluronate     NI...  K             0896  ..........      124.68  ..........       24.94
                 Injection.
J7320.........  Hylan G-F 20           CH...  D       ..........  ..........  ..........  ..........  ..........
                 injection.
J7340.........  Metabolic active D/E  ......  K             1632  ..........       27.89  ..........        5.58
                 tissue.
J7341.........  Non-human, metabolic  ......  K             1707  ..........        1.78  ..........        0.36
                 tissue.
J7342.........  Metabolically active  ......  K             9054  ..........       13.87  ..........        2.77
                 tissue.
J7343.........  Nonmetabolic act d/e  ......  K             1629  ..........       18.49  ..........        3.70
                 tissue.
J7344.........  Nonmetabolic active   ......  K             9156  ..........       45.02  ..........        9.00
                 tissue.
J7345.........  Non-human, non-metab   NI...  B       ..........  ..........  ..........  ..........  ..........
                 tissue.
J7346.........  Injectable human       NI...  K             9222  ..........      743.96  ..........      148.79
                 tissue.
J7350.........  Injectable human       CH...  D       ..........  ..........  ..........  ..........  ..........
                 tissue.
J7500.........  Azathioprine oral     ......  N       ..........  ..........  ..........  ..........  ..........
                 50mg.
J7501.........  Azathioprine          ......  K             0887  ..........       49.17  ..........        9.83
                 parenteral.
J7502.........  Cyclosporine oral     ......  K             0888  ..........        3.66  ..........        0.73
                 100 mg.
J7504.........  Lymphocyte immune     ......  K             0890  ..........      315.76  ..........       63.15
                 globulin.
J7505.........  Monoclonal            ......  K             7038  ..........      856.05  ..........      171.21
                 antibodies.
J7506.........  Prednisone oral.....  ......  N       ..........  ..........  ..........  ..........  ..........
J7507.........  Tacrolimus oral per   ......  K             0891  ..........        3.55  ..........        0.71
                 1 MG.
J7509.........  Methylprednisolone    ......  N       ..........  ..........  ..........  ..........  ..........
                 oral.
J7510.........  Prednisolone oral     ......  N       ..........  ..........  ..........  ..........  ..........
                 per 5 mg.
J7511.........  Antithymocyte         ......  K             9104  ..........      329.62  ..........       65.92
                 globuln rabbit.
J7513.........  Daclizumab,           ......  K             1612  ..........      328.83  ..........       65.77
                 parenteral.
J7515.........  Cyclosporine oral 25   CH...  N       ..........  ..........  ..........  ..........  ..........
                 mg.
J7516.........  Cyclosporin           ......  N       ..........  ..........  ..........  ..........  ..........
                 parenteral 250mg.
J7517.........  Mycophenolate         ......  K             9015  ..........        2.50  ..........        0.50
                 mofetil oral.
J7518.........  Mycophenolic acid...   CH...  K             9219  ..........        2.15  ..........        0.43
J7520.........  Sirolimus, oral.....  ......  K             9020  ..........        7.25  ..........        1.45
J7525.........  Tacrolimus injection  ......  K             9006  ..........      140.72  ..........       28.14
J7599.........  Immunosuppressive     ......  N       ..........  ..........  ..........  ..........  ..........
                 drug noc.
J7607.........  Levalbuterol comp      NI...  B       ..........  ..........  ..........  ..........  ..........
                 con.
J7609.........  Albuterol comp unit.   NI...  B       ..........  ..........  ..........  ..........  ..........
J7610.........  Albuterol comp con..   NI...  B       ..........  ..........  ..........  ..........  ..........

[[Page 68379]]

 
J7615.........  Levalbuterol comp      NI...  B       ..........  ..........  ..........  ..........  ..........
                 unit.
J7634.........  Budesonide comp con.   NI...  B       ..........  ..........  ..........  ..........  ..........
J7645.........  Ipratropium bromide    NI...  B       ..........  ..........  ..........  ..........  ..........
                 comp.
J7647.........  Isoetharine comp con   NI...  B       ..........  ..........  ..........  ..........  ..........
J7650.........  Isoetharine comp       NI...  B       ..........  ..........  ..........  ..........  ..........
                 unit.
J7657.........  Isoproterenol comp     NI...  B       ..........  ..........  ..........  ..........  ..........
                 con.
J7660.........  Isoproterenol comp     NI...  B       ..........  ..........  ..........  ..........  ..........
                 unit.
J7667.........  Metaproterenol comp    NI...  B       ..........  ..........  ..........  ..........  ..........
                 con.
J7670.........  Metaproterenol comp    NI...  B       ..........  ..........  ..........  ..........  ..........
                 unit.
J7674.........  Methacholine          ......  N       ..........  ..........  ..........  ..........  ..........
                 chloride, neb.
J7685.........  Tobramycin comp unit   NI...  B       ..........  ..........  ..........  ..........  ..........
J7799.........  Non-inhalation drug   ......  N       ..........  ..........  ..........  ..........  ..........
                 for DME.
J8501.........  Oral aprepitant.....  ......  G             0868  ..........        4.85  ..........        0.97
J8510.........  Oral busulfan.......  ......  K             7015  ..........        2.14  ..........        0.43
J8520.........  Capecitabine, oral,   ......  K             7042  ..........        3.83  ..........        0.77
                 150 mg.
J8530.........  Cyclophosphamide      ......  N       ..........  ..........  ..........  ..........  ..........
                 oral 25 MG.
J8540.........  Oral dexamethasone..   CH...  N       ..........  ..........  ..........  ..........  ..........
J8560.........  Etoposide oral 50 MG  ......  K             0802  ..........       32.01  ..........        6.40
J8597.........  Antiemetic drug oral  ......  N       ..........  ..........  ..........  ..........  ..........
                 NOS.
J8600.........  Melphalan oral 2 MG.  ......  N       ..........  ..........  ..........  ..........  ..........
J8610.........  Methotrexate oral     ......  N       ..........  ..........  ..........  ..........  ..........
                 2.5 MG.
J8650.........  Nabilone oral.......   NI...  K             0808  ..........       16.96  ..........        3.39
J8700.........  Temozolomide........  ......  K             1086  ..........        7.30  ..........        1.46
J9000.........  Doxorubic hcl 10 MG    CH...  K             3048  ..........        6.00  ..........        1.20
                 vl chemo.
J9001.........  Doxorubicin hcl       ......  K             7046  ..........      379.21  ..........       75.84
                 liposome inj.
J9010.........  Alemtuzumab           ......  K             9110  ..........      531.24  ..........      106.25
                 injection.
J9015.........  Aldesleukin/single    ......  K             0807  ..........      726.69  ..........      145.34
                 use vial.
J9017.........  Arsenic trioxide....  ......  K             9012  ..........       33.36  ..........        6.67
J9020.........  Asparaginase          ......  K             0814  ..........       54.46  ..........       10.89
                 injection.
J9025.........  Azacitidine           ......  K             1709  ..........        4.22  ..........        0.84
                 injection.
J9027.........  Clofarabine           ......  G             1710  ..........      116.62  ..........       23.32
                 injection.
J9031.........  Bcg live              ......  K             0809  ..........      113.44  ..........       22.69
                 intravesical vac.
J9035.........  Bevacizumab            CH...  K             9214  ..........       56.88  ..........       11.38
                 injection.
J9040.........  Bleomycin sulfate      CH...  K             0748  ..........       37.62  ..........        7.52
                 injection.
J9041.........  Bortezomib injection  ......  K             9207  ..........       31.87  ..........        6.37
J9045.........  Carboplatin           ......  K             0811  ..........       10.12  ..........        2.02
                 injection.
J9050.........  Carmus bischl nitro   ......  K             0812  ..........      139.84  ..........       27.97
                 inj.
J9055.........  Cetuximab injection.   CH...  K             9215  ..........       49.86  ..........        9.97
J9060.........  Cisplatin 10 MG       ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J9065.........  Inj cladribine per 1  ......  K             0858  ..........       37.87  ..........        7.57
                 MG.
J9070.........  Cyclophosphamide 100  ......  N       ..........  ..........  ..........  ..........  ..........
                 MG inj.
J9093.........  Cyclophosphamide       CH...  K             3049  ..........        5.72  ..........        1.14
                 lyophilized.
J9098.........  Cytarabine liposome.  ......  K             1166  ..........      396.66  ..........       79.33
J9100.........  Cytarabine hcl 100    ......  N       ..........  ..........  ..........  ..........  ..........
                 MG inj.
J9120.........  Dactinomycin           CH...  K             0752  ..........      493.43  ..........       98.69
                 actinomycin d.
J9130.........  Dacarbazine 100 mg     CH...  K             0746  ..........        4.90  ..........        0.98
                 inj.
J9150.........  Daunorubicin........  ......  K             0820  ..........       24.56  ..........        4.91
J9151.........  Daunorubicin citrate  ......  K             0821  ..........       56.21  ..........       11.24
                 liposom.
J9160.........  Denileukin diftitox,  ......  K             1084  ..........    1,403.23  ..........      280.65
                 300 mcg.
J9165.........  Diethylstilbestrol    ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J9170.........  Docetaxel...........  ......  K             0823  ..........      302.68  ..........       60.54
J9175.........  Elliotts b solution   ......  N       ..........  ..........  ..........  ..........  ..........
                 per ml.
J9178.........  Inj, epirubicin hcl,  ......  K             1167  ..........       24.67  ..........        4.93
                 2 mg.
J9181.........  Etoposide 10 MG inj.  ......  N       ..........  ..........  ..........  ..........  ..........
J9185.........  Fludarabine           ......  K             0842  ..........      243.82  ..........       48.76
                 phosphate inj.
J9190.........  Fluorouracil          ......  N       ..........  ..........  ..........  ..........  ..........
                 injection.
J9200.........  Floxuridine           ......  K             0827  ..........       64.17  ..........       12.83
                 injection.
J9201.........  Gemcitabine HCl.....  ......  K             0828  ..........      121.30  ..........       24.26
J9202.........  Goserelin acetate     ......  K             0810  ..........      199.12  ..........       39.82
                 implant.
J9206.........  Irinotecan injection  ......  K             0830  ..........      126.88  ..........       25.38
J9208.........  Ifosfomide injection  ......  K             0831  ..........       52.39  ..........       10.48
J9209.........  Mesna injection.....  ......  K             0732  ..........       10.10  ..........        2.02
J9211.........  Idarubicin hcl        ......  K             0832  ..........      308.97  ..........       61.79
                 injection.
J9212.........  Interferon alfacon-1  ......  K             0912  ..........        4.65  ..........        0.93
J9213.........  Interferon alfa-2a    ......  K             0834  ..........       37.56  ..........        7.51
                 inj.
J9214.........  Interferon alfa-2b    ......  K             0836  ..........       13.75  ..........        2.75
                 inj.
J9215.........  Interferon alfa-n3    ......  K             0865  ..........       39.48  ..........        7.90
                 inj.
J9216.........  Interferon gamma 1-b  ......  K             0838  ..........      289.87  ..........       57.97
                 inj.
J9217.........  Leuprolide acetate    ......  K             9217  ..........      227.63  ..........       45.53
                 suspnsion.
J9218.........  Leuprolide acetate    ......  K             0861  ..........       11.10  ..........        2.22
                 injeciton.

[[Page 68380]]

 
J9219.........  Leuprolide acetate    ......  K             7051  ..........    2,208.90  ..........      441.78
                 implant.
J9225.........  Histrelin implant...  ......  K             1711  ..........    1,741.71  ..........      348.34
J9230.........  Mechlorethamine hcl    CH...  K             0751  ..........      141.61  ..........       28.32
                 inj.
J9245.........  Inj melphalan         ......  K             0840  ..........    1,194.15  ..........      238.83
                 hydrochl 50 MG.
J9250.........  Methotrexate sodium   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J9261.........  Nelarabine injection   NI...  K             0825  ..........       83.10  ..........       16.62
J9263.........  Oxaliplatin.........  ......  K             1738  ..........        8.77  ..........        1.75
J9264.........  Paclitaxel protein    ......  G             1712  ..........        8.73  ..........        1.75
                 bound.
J9265.........  Paclitaxel injection  ......  K             0863  ..........       14.35  ..........        2.87
J9266.........  Pegaspargase/singl    ......  K             0843  ..........    1,687.04  ..........      337.41
                 dose vial.
J9268.........  Pentostatin           ......  K             0844  ..........    2,034.63  ..........      406.93
                 injection.
J9270.........  Plicamycin            ......  K             0860  ..........       61.36  ..........       12.27
                 (mithramycin) inj.
J9280.........  Mitomycin 5 MG inj..  ......  K             0862  ..........       18.31  ..........        3.66
J9293.........  Mitoxantrone          ......  K             0864  ..........      223.27  ..........       44.65
                 hydrochl / 5 MG.
J9300.........  Gemtuzumab            ......  K             9004  ..........    2,317.16  ..........      463.43
                 ozogamicin.
J9305.........  Pemetrexed injection   CH...  K             9213  ..........       42.49  ..........        8.50
J9310.........  Rituximab cancer      ......  K             0849  ..........      481.69  ..........       96.34
                 treatment.
J9320.........  Streptozocin          ......  K             0850  ..........      152.92  ..........       30.58
                 injection.
J9340.........  Thiotepa injection..  ......  K             0851  ..........       44.58  ..........        8.92
J9350.........  Topotecan...........  ......  K             0852  ..........      813.08  ..........      162.62
J9355.........  Trastuzumab.........  ......  K             1613  ..........       56.17  ..........       11.23
J9357.........  Valrubicin, 200 mg..  ......  K             9167  ..........      369.60  ..........       73.92
J9360.........  Vinblastine sulfate   ......  N       ..........  ..........  ..........  ..........  ..........
                 inj.
J9370.........  Vincristine sulfate   ......  N       ..........  ..........  ..........  ..........  ..........
                 1 MG inj.
J9390.........  Vinorelbine tartrate/ ......  K             0855  ..........       22.82  ..........        4.56
                 10 mg.
J9395.........  Injection,            ......  K             9120  ..........       80.66  ..........       16.13
                 Fulvestrant.
J9600.........  Porfimer sodium.....  ......  K             0856  ..........    2,505.40  ..........      501.08
J9999.........  Chemotherapy drug...  ......  N       ..........  ..........  ..........  ..........  ..........
K0090.........  Rear tire power        CH...  D       ..........  ..........  ..........  ..........  ..........
                 wheelchair.
K0091.........  Rear tire tube power   CH...  D       ..........  ..........  ..........  ..........  ..........
                 whlchr.
K0092.........  Rear assem cmplt       CH...  D       ..........  ..........  ..........  ..........  ..........
                 powr whlchr.
K0093.........  Rear zero pressure     CH...  D       ..........  ..........  ..........  ..........  ..........
                 tire tube.
K0094.........  Wheel tire for power   CH...  D       ..........  ..........  ..........  ..........  ..........
                 base.
K0095.........  Wheel tire tube each   CH...  D       ..........  ..........  ..........  ..........  ..........
                 base.
K0096.........  Wheel assem powr       CH...  D       ..........  ..........  ..........  ..........  ..........
                 base complt.
K0097.........  Wheel zero presure     CH...  D       ..........  ..........  ..........  ..........  ..........
                 tire tube.
K0098.........  Drive belt power       CH...  D       ..........  ..........  ..........  ..........  ..........
                 wheelchair.
K0733.........  12-24hr sealed lead    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 acid.
K0734.........  Adj skin pro w/c cus   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 wd<22in.
K0735.........  Adj skin pro wc cus    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 wd[gE]22in.
K0736.........  Adj skin pro/pos wc    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 cus<22in.
K0737.........  Adj skin pro/pos wc    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 cus[gE]22.
K0738.........  Portable gas oxygen    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 system.
K0800.........  POV group 1 std up     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 to 300 lb.
K0801.........  POV group 1 hd 301-    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 450 lbs.
K0802.........  POV group 1 vhd 451-   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 600 lbs.
K0806.........  POV group 2 std up     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 to 300lbs.
K0807.........  POV group 2 hd 301-    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 450 lbs.
K0808.........  POV group 2 vhd 451-   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 600 lbs.
K0812.........  Power operated         NI...  Y       ..........  ..........  ..........  ..........  ..........
                 vehicle NOC.
K0813.........  PWC gp 1 std port      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 seat/back.
K0814.........  PWC gp 1 std port      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 cap chair.
K0815.........  PWC gp 1 std seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0816.........  PWC gp 1 std cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0820.........  PWC gp 2 std port      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 seat/back.
K0821.........  PWC gp 2 std port      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 cap chair.
K0822.........  PWC gp 2 std seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0823.........  PWC gp 2 std cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0824.........  PWC gp 2 hd seat/      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0825.........  PWC gp 2 hd cap        NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0826.........  PWC gp2 vhd seat/      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0827.........  PWC gp 2 vhd cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0828.........  PWC gp 2 xtra hd       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 seat/back.
K0829.........  PWC gp 2 xtra hd cap   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0830.........  PWC gp2 std seat       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 elevate s/b.
K0831.........  PWC gp2 std seat       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 elevate cap.
K0835.........  PWC gp2 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0836.........  PWC gp2 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0837.........  PWC gp 2 hd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0838.........  PWC gp 2 hd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.

[[Page 68381]]

 
K0839.........  PWC gp2 vhd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0840.........  PWC gp2 xhd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0841.........  PWC gp2 std mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0842.........  PWC gp2 std mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0843.........  PWC gp2 hd mult pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0848.........  PWC gp 3 std seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0849.........  PWC gp 3 std cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0850.........  PWC gp 3 hd seat/      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0851.........  PWC gp 3 hd cap        NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0852.........  PWC gp 3 vhd seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0853.........  PWC gp 3 vhd cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0854.........  PWC gp 3 xhd seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0855.........  PWC gp 3 xhd cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0856.........  PWC gp3 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0857.........  PWC gp3 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0858.........  PWC gp3 hd sing pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0859.........  PWC gp3 hd sing pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0860.........  PWC gp3 vhd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0861.........  PWC gp3 std mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0862.........  PWC gp3 hd mult pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0863.........  PWC gp3 vhd mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0864.........  PWC gp3 xhd mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0868.........  PWC gp 4 std seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0869.........  PWC gp 4 std cap       NI...  Y       ..........  ..........  ..........  ..........  ..........
                 chair.
K0870.........  PWC gp 4 hd seat/      NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0871.........  PWC gp 4 vhd seat/     NI...  Y       ..........  ..........  ..........  ..........  ..........
                 back.
K0877.........  PWC gp4 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0878.........  PWC gp4 std sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0879.........  PWC gp4 hd sing pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0880.........  PWC gp4 vhd sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0884.........  PWc gp4 std mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0885.........  PWC gp4 std mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt cap.
K0886.........  PWC gp4 hd mult pow    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 s/b.
K0890.........  PWC gp5 ped sing pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0891.........  PWC gp5 ped mult pow   NI...  Y       ..........  ..........  ..........  ..........  ..........
                 opt s/b.
K0898.........  Power wheelchair NOC   NI...  Y       ..........  ..........  ..........  ..........  ..........
K0899.........  Pow mobility dev no    NI...  Y       ..........  ..........  ..........  ..........  ..........
                 sadmerc.
L0100.........  Cranial orthosis/      CH...  D       ..........  ..........  ..........  ..........  ..........
                 helmet mold.
L0110.........  Cranial orthosis/      CH...  D       ..........  ..........  ..........  ..........  ..........
                 helmet nonm.
L1001.........  CTLSO infant           NI...  A       ..........  ..........  ..........  ..........  ..........
                 immobilizer.
L3806.........  WHFO w/joint(s)        NI...  A       ..........  ..........  ..........  ..........  ..........
                 custom fab.
L3808.........  WHFO, rigid w/o        NI...  A       ..........  ..........  ..........  ..........  ..........
                 joints.
L3902.........  Whfo ext power         CH...  D       ..........  ..........  ..........  ..........  ..........
                 compress gas.
L3914.........  WHO wrist extension    CH...  D       ..........  ..........  ..........  ..........  ..........
                 cock-up.
L3915.........  WHO w nontor jnt(s)    NI...  A       ..........  ..........  ..........  ..........  ..........
                 prefab.
L5993.........  Heavy duty feature,    NI...  A       ..........  ..........  ..........  ..........  ..........
                 foot.
L5994.........  Heavy duty feature,    NI...  A       ..........  ..........  ..........  ..........  ..........
                 knee.
L6611.........  Additional switch,     NI...  A       ..........  ..........  ..........  ..........  ..........
                 ext power.
L6624.........  Flex/ext/rotation      NI...  A       ..........  ..........  ..........  ..........  ..........
                 wrist unit.
L6639.........  Heavy duty elbow       NI...  A       ..........  ..........  ..........  ..........  ..........
                 feature.
L6700.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 3.
L6703.........  Term dev, passive      NI...  A       ..........  ..........  ..........  ..........  ..........
                 hand mitt.
L6704.........  Term dev, sport/rec/   NI...  A       ..........  ..........  ..........  ..........  ..........
                 work att.
L6705.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 5.
L6706.........  Term dev mech hook     NI...  A       ..........  ..........  ..........  ..........  ..........
                 vol open.
L6707.........  Term dev mech hook     NI...  A       ..........  ..........  ..........  ..........  ..........
                 vol close.
L6708.........  Term dev mech hand     NI...  A       ..........  ..........  ..........  ..........  ..........
                 vol open.
L6709.........  Term dev mech hand     NI...  A       ..........  ..........  ..........  ..........  ..........
                 vol close.
L6710.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 5x.
L6715.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 5xa.
L6720.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 6.
L6725.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 7.
L6730.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 7lo.
L6735.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 8.
L6740.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 8x.
L6745.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 88x.
L6750.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 10p.
L6755.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 10x.
L6765.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 12p.
L6770.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model 99x.

[[Page 68382]]

 
L6775.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model555.
L6780.........  Terminal device        CH...  D       ..........  ..........  ..........  ..........  ..........
                 model ss555.
L6790.........  Hooks-accu hook or     CH...  D       ..........  ..........  ..........  ..........  ..........
                 equal.
L6795.........  Hooks-2 load or        CH...  D       ..........  ..........  ..........  ..........  ..........
                 equal.
L6800.........  Hooks-aprl vc or       CH...  D       ..........  ..........  ..........  ..........  ..........
                 equal.
L6806.........  Trs grip vc or equal   CH...  D       ..........  ..........  ..........  ..........  ..........
L6807.........  Term device grip1/2    CH...  D       ..........  ..........  ..........  ..........  ..........
                 or equal.
L6808.........  Term device infant     CH...  D       ..........  ..........  ..........  ..........  ..........
                 or child.
L6809.........  Trs super sport        CH...  D       ..........  ..........  ..........  ..........  ..........
                 passive.
L6825.........  Hands dorrance vo...   CH...  D       ..........  ..........  ..........  ..........  ..........
L6830.........  Hand aprl vc........   CH...  D       ..........  ..........  ..........  ..........  ..........
L6835.........  Hand sierra vo......   CH...  D       ..........  ..........  ..........  ..........  ..........
L6840.........  Hand becker imperial   CH...  D       ..........  ..........  ..........  ..........  ..........
L6845.........  Hand becker lock       CH...  D       ..........  ..........  ..........  ..........  ..........
                 grip.
L6850.........  Term dvc-hand becker   CH...  D       ..........  ..........  ..........  ..........  ..........
                 plylite.
L6855.........  Hand robin-aids vo..   CH...  D       ..........  ..........  ..........  ..........  ..........
L6860.........  Hand robin-aids vo     CH...  D       ..........  ..........  ..........  ..........  ..........
                 soft.
L6865.........  Hand passive hand...   CH...  D       ..........  ..........  ..........  ..........  ..........
L6867.........  Hand detroit infant    CH...  D       ..........  ..........  ..........  ..........  ..........
                 hand.
L6868.........  Passive inf hand       CH...  D       ..........  ..........  ..........  ..........  ..........
                 steeper/hos.
L6870.........  Hand child mitt.....   CH...  D       ..........  ..........  ..........  ..........  ..........
L6872.........  Hand nyu child hand.   CH...  D       ..........  ..........  ..........  ..........  ..........
L6873.........  Hand mech inf          CH...  D       ..........  ..........  ..........  ..........  ..........
                 steeper or equ.
L6875.........  Hand bock vc........   CH...  D       ..........  ..........  ..........  ..........  ..........
L6880.........  Hand bock vo........   CH...  D       ..........  ..........  ..........  ..........  ..........
L7007.........  Adult electric hand.   NI...  A       ..........  ..........  ..........  ..........  ..........
L7008.........  Pediatric electric     NI...  A       ..........  ..........  ..........  ..........  ..........
                 hand.
L7009.........  Adult electric hook.   NI...  A       ..........  ..........  ..........  ..........  ..........
L7010.........  Hand otto back         CH...  D       ..........  ..........  ..........  ..........  ..........
                 steeper/eq sw.
L7015.........  Hand sys teknik        CH...  D       ..........  ..........  ..........  ..........  ..........
                 village swit.
L7020.........  Electronic greifer     CH...  D       ..........  ..........  ..........  ..........  ..........
                 switch ct.
L7025.........  Electron hand          CH...  D       ..........  ..........  ..........  ..........  ..........
                 myoelectronic.
L7030.........  Hand sys teknik vill   CH...  D       ..........  ..........  ..........  ..........  ..........
                 myoelec.
L7035.........  Electron greifer       CH...  D       ..........  ..........  ..........  ..........  ..........
                 myoelectro.
L8600.........  Implant breast        ......  N       ..........  ..........  ..........  ..........  ..........
                 silicone/eq.
L8603.........  Collagen imp urinary  ......  N       ..........  ..........  ..........  ..........  ..........
                 2.5 ml.
L8606.........  Synthetic implnt      ......  N       ..........  ..........  ..........  ..........  ..........
                 urinary 1ml.
L8609.........  Artificial cornea...  ......  N       ..........  ..........  ..........  ..........  ..........
L8610.........  Ocular implant......  ......  N       ..........  ..........  ..........  ..........  ..........
L8612.........  Aqueous shunt         ......  N       ..........  ..........  ..........  ..........  ..........
                 prosthesis.
L8613.........  Ossicular implant...  ......  N       ..........  ..........  ..........  ..........  ..........
L8614.........  Cochlear device.....  ......  N       ..........  ..........  ..........  ..........  ..........
L8630.........  Metacarpophalangeal   ......  N       ..........  ..........  ..........  ..........  ..........
                 implant.
L8631.........  MCP joint repl 2 pc   ......  N       ..........  ..........  ..........  ..........  ..........
                 or more.
L8641.........  Metatarsal joint      ......  N       ..........  ..........  ..........  ..........  ..........
                 implant.
L8642.........  Hallux implant......  ......  N       ..........  ..........  ..........  ..........  ..........
L8658.........  Interphalangeal       ......  N       ..........  ..........  ..........  ..........  ..........
                 joint spacer.
L8659.........  Interphalangeal       ......  N       ..........  ..........  ..........  ..........  ..........
                 joint repl.
L8670.........  Vascular graft,       ......  N       ..........  ..........  ..........  ..........  ..........
                 synthetic.
L8682.........  Implt neurostim       ......  N       ..........  ..........  ..........  ..........  ..........
                 radiofq rec.
L8690.........  Aud osseo dev, int/    NI...  H             1032  ..........  ..........  ..........  ..........
                 ext comp.
L8691.........  Aud osseo dev, int/    NI...  A       ..........  ..........  ..........  ..........  ..........
                 ext comp.
L8695.........  External recharg sys   NI...  A       ..........  ..........  ..........  ..........  ..........
                 extern.
L8699.........  Prosthetic implant    ......  N       ..........  ..........  ..........  ..........  ..........
                 NOS.
M0064.........  Visit for drug        ......  X             0374      1.1418       70.18  ..........       14.04
                 monitoring.
P9010.........  Whole blood for       ......  K             0950      2.1472      131.98  ..........       26.40
                 transfusion.
P9011.........  Blood split unit....  ......  K             0967      2.2323      137.22  ..........       27.44
P9012.........  Cryoprecipitate each  ......  K             0952      0.7905       48.59  ..........        9.72
                 unit.
P9016.........  RBC leukocytes        ......  K             0954       2.859      175.74  ..........       35.15
                 reduced.
P9017.........  Plasma 1 donor frz w/ ......  K             9508      1.1422       70.21  ..........       14.04
                 in 8 hr.
P9019.........  Platelets, each unit  ......  K             0957       0.959       58.95  ..........       11.79
P9020.........  Plaelet rich plasma   ......  K             0958      3.4048      209.29  ..........       41.86
                 unit.
P9021.........  Red blood cells unit  ......  K             0959      2.1073      129.53  ..........       25.91
P9022.........  Washed red blood      ......  K             0960      3.4331      211.03  ..........       42.21
                 cells unit.
P9023.........  Frozen plasma,        ......  K             0949      0.9346       57.45  ..........       11.49
                 pooled, sd.
P9031.........  Platelets leukocytes  ......  K             1013      1.5469       95.08  ..........       19.02
                 reduced.
P9032.........  Platelets,            ......  K             9500      2.1079      129.57  ..........       25.91
                 irradiated.
P9033.........  Platelets             ......  K             0968       2.039      125.33  ..........       25.07
                 leukoreduced irrad.
P9034.........  Platelets, pheresis.  ......  K             9507      7.3686      452.93  ..........       90.59
P9035.........  Platelet pheres       ......  K             9501      7.9511      488.74  ..........       97.75
                 leukoreduced.

[[Page 68383]]

 
P9036.........  Platelet pheresis     ......  K             9502      6.8088      418.52  ..........       83.70
                 irradiated.
P9037.........  Plate pheres          ......  K             1019     10.0443      617.40  ..........      123.48
                 leukoredu irrad.
P9038.........  RBC irradiated......  ......  K             9505      3.2049      197.00  ..........       39.40
P9039.........  RBC deglycerolized..  ......  K             9504      5.8292      358.31  ..........       71.66
P9040.........  RBC leukoreduced      ......  K             0969      3.5394      217.56  ..........       43.51
                 irradiated.
P9041.........  Albumin (human),5%,   ......  K             0961  ..........       29.68  ..........        5.94
                 50ml.
P9043.........  Plasma protein        ......  K             0956      0.8339       51.26  ..........       10.25
                 fract,5%,50ml.
P9044.........  Cryoprecipitatereduc  ......  K             1009      1.3404       82.39  ..........       16.48
                 edplasma.
P9045.........  Albumin (human), 5%,  ......  K             0963  ..........       76.81  ..........       15.36
                 250 ml.
P9046.........  Albumin (human),      ......  K             0964  ..........       28.80  ..........        5.76
                 25%, 20 ml.
P9047.........  Albumin (human),      ......  K             0965  ..........       65.26  ..........       13.05
                 25%, 50ml.
P9048.........  Plasmaprotein         ......  K             0966      3.8746      238.16  ..........       47.63
                 fract,5%,250ml.
P9050.........  Granulocytes,         ......  K             9506     12.2073      750.36  ..........      150.07
                 pheresis unit.
P9051.........  Blood, l/r, cmv-neg.  ......  K             1010      2.5493      156.70  ..........       31.34
P9052.........  Platelets, hla-m, l/  ......  K             1011     10.9263      671.62  ..........      134.32
                 r, unit.
P9053.........  Plt, pher, l/r cmv-   ......  K             1020     11.4755      705.38  ..........      141.08
                 neg, irr.
P9054.........  Blood, l/r, froz/     ......  K             1016      3.4335      211.05  ..........       42.21
                 degly/wash.
P9055.........  Plt, aph/pher, l/r,   ......  K             1017      6.4556      396.81  ..........       79.36
                 cmv-neg.
P9056.........  Blood, l/r,           ......  K             1018      2.3472      144.28  ..........       28.86
                 irradiated.
P9057.........  RBC, frz/deg/wsh, l/  ......  K             1021      8.0727      496.21  ..........       99.24
                 r, irrad.
P9058.........  RBC, l/r, cmv-neg,    ......  K             1022      4.2653      262.18  ..........       52.44
                 irrad.
P9059.........  Plasma, frz between   ......  K             0955      1.2489       76.77  ..........       15.35
                 8-24hour.
P9060.........  Fr frz plasma donor   ......  K             9503      1.2119       74.49  ..........       14.90
                 retested.
P9612.........  Catheterize for        CH...  A       ..........  ..........  ..........  ..........  ..........
                 urine spec.
P9615.........  Urine specimen        ......  N       ..........  ..........  ..........  ..........  ..........
                 collect mult.
Q0035.........  Cardiokymography....  ......  X             0100      2.5336      155.74       41.44       31.15
Q0091.........  Obtaining screen pap  ......  T             0191      0.1468        9.02        2.55        1.80
                 smear.
Q0092.........  Set up port xray      ......  N       ..........  ..........  ..........  ..........  ..........
                 equipment.
Q0163.........  Diphenhydramine HCl   ......  N       ..........  ..........  ..........  ..........  ..........
                 50mg.
Q0164.........  Prochlorperazine      ......  N       ..........  ..........  ..........  ..........  ..........
                 maleate 5mg.
Q0166.........  Granisetron HCl 1 mg  ......  K             0765  ..........       41.18  ..........        8.24
                 oral.
Q0167.........  Dronabinol 2.5mg      ......  N       ..........  ..........  ..........  ..........  ..........
                 oral.
Q0169.........  Promethazine HCl      ......  N       ..........  ..........  ..........  ..........  ..........
                 12.5mg oral.
Q0171.........  Chlorpromazine HCl    ......  N       ..........  ..........  ..........  ..........  ..........
                 10mg oral.
Q0173.........  Trimethobenzamide     ......  N       ..........  ..........  ..........  ..........  ..........
                 HCl 250mg.
Q0174.........  Thiethylperazine      ......  N       ..........  ..........  ..........  ..........  ..........
                 maleate10mg.
Q0175.........  Perphenazine 4mg      ......  N       ..........  ..........  ..........  ..........  ..........
                 oral.
Q0177.........  Hydroxyzine pamoate   ......  N       ..........  ..........  ..........  ..........  ..........
                 25mg.
Q0179.........  Ondansetron HCl 8mg   ......  K             0769  ..........       36.06  ..........        7.21
                 oral.
Q0180.........  Dolasetron mesylate   ......  K             0763  ..........       48.91  ..........        9.78
                 oral.
Q0512.........  Px sup fee anti-can    CH...  B       ..........  ..........  ..........  ..........  ..........
                 sub pres.
Q0515.........  Sermorelin acetate     CH...  K             3050  ..........        1.75  ..........        0.35
                 injection.
Q1003.........  NTIOL category 3....  ......  N       ..........  ..........  ..........  ..........  ..........
Q1004.........  Ntiol category 4....  ......  N       ..........  ..........  ..........  ..........  ..........
Q1005.........  Ntiol category 5....  ......  N       ..........  ..........  ..........  ..........  ..........
Q2004.........  Bladder calculi       ......  N       ..........  ..........  ..........  ..........  ..........
                 irrig sol.
Q2009.........  Fosphenytoin, 50 mg.  ......  K             7028  ..........        5.59  ..........        1.12
Q2017.........  Teniposide, 50 mg...  ......  K             7035  ..........      264.88  ..........       52.98
Q3025.........  IM inj interferon     ......  K             9022  ..........      108.04  ..........       21.61
                 beta 1-a.
Q3031.........  Collagen skin test..  ......  N       ..........  ..........  ..........  ..........  ..........
Q4079.........  Natalizumab           ......  G             9126  ..........        7.72  ..........        1.54
                 injection.
Q4081.........  Epoetin alfa, 100      NI...  A       ..........  ..........  ..........  ..........  ..........
                 units ESRD.
Q4082.........  Drug/bio NOC part B    NI...  B       ..........  ..........  ..........  ..........  ..........
                 drug CAP.
Q5001.........  Hospice in patient     NI...  B       ..........  ..........  ..........  ..........  ..........
                 home.
Q5002.........  Hospice in assisted    NI...  B       ..........  ..........  ..........  ..........  ..........
                 living.
Q5003.........  Hospice in LT/non-     NI...  B       ..........  ..........  ..........  ..........  ..........
                 skilled NF.
Q5004.........  Hospice in SNF......   NI...  B       ..........  ..........  ..........  ..........  ..........
Q5005.........  Hospice, inpatient     NI...  B       ..........  ..........  ..........  ..........  ..........
                 hospital.
Q5006.........  Hospice in hospice     NI...  B       ..........  ..........  ..........  ..........  ..........
                 facility.
Q5007.........  Hospice in LTCH.....   NI...  B       ..........  ..........  ..........  ..........  ..........
Q5008.........  Hospice in inpatient   NI...  B       ..........  ..........  ..........  ..........  ..........
                 psych.
Q5009.........  Hospice care, NOS...   NI...  B       ..........  ..........  ..........  ..........  ..........
Q9945.........  LOCM [lE]149 mg/ml    ......  K             9157  ..........        0.29  ..........        0.06
                 iodine, 1ml.
Q9946.........  LOCM 150-199mg/ml     ......  K             9158  ..........        1.96  ..........        0.39
                 iodine,1ml.
Q9947.........  LOCM 200-249mg/ml     ......  K             9159  ..........        1.42  ..........        0.28
                 iodine,1ml.
Q9948.........  LOCM 250-299mg/ml     ......  K             9160  ..........        0.27  ..........        0.05
                 iodine,1ml.
Q9949.........  LOCM 300-349mg/ml     ......  K             9161  ..........        0.35  ..........        0.07
                 iodine,1ml.
Q9950.........  LOCM 350-399mg/ml     ......  K             9162  ..........        0.21  ..........        0.04
                 iodine,1ml.
Q9951.........  LOCM [gE] 400 mg/ml   ......  K             9163  ..........        0.30  ..........        0.06
                 iodine,1ml.
Q9952.........  Inj Gad-base MR       ......  K             9164  ..........        2.87  ..........        0.57
                 contrast,1ml.

[[Page 68384]]

 
Q9953.........  Inj Fe-based MR       ......  K             1713  ..........       30.41  ..........        6.08
                 contrast,1ml.
Q9954.........  Oral MR contrast,     ......  K             9165  ..........        8.90  ..........        1.78
                 100 ml.
Q9955.........  Inj perflexane lip    ......  K             9203  ..........        7.05  ..........        1.41
                 micros,ml.
Q9956.........  Inj                   ......  K             9202  ..........       49.61  ..........        9.92
                 octafluoropropane
                 mic,ml.
Q9957.........  Inj perflutren lip    ......  K             9112  ..........       61.64  ..........       12.33
                 micros,ml.
Q9958.........  HOCM [lE]149 mg/ml     CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine, 1ml.
Q9959.........  HOCM 150-199mg/ml     ......  N       ..........  ..........  ..........  ..........  ..........
                 iodine,1ml.
Q9960.........  HOCM 200-249mg/ml      CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine,1ml.
Q9961.........  HOCM 250-299mg/ml      CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine,1ml.
Q9962.........  HOCM 300-349mg/ml      CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine,1ml.
Q9963.........  HOCM 350-399mg/ml      CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine,1ml.
Q9964.........  HOCM[gE] 400mg/ml      CH...  N       ..........  ..........  ..........  ..........  ..........
                 iodine, 1ml.
V2630.........  Anter chamber         ......  N       ..........  ..........  ..........  ..........  ..........
                 intraocul lens.
V2631.........  Iris support          ......  N       ..........  ..........  ..........  ..........  ..........
                 intraoclr lens.
V2632.........  Post chmbr            ......  N       ..........  ..........  ..........  ..........  ..........
                 intraocular lens.
V2790.........  Amniotic membrane...  ......  N       ..........  ..........  ..........  ..........  ..........
----------------------------------------------------------------------------------------------------------------


                 Addendum D1.--Payment Status Indicators
------------------------------------------------------------------------
      Indicator           Item/code/service        OPPS payment status
------------------------------------------------------------------------
A...................  Services furnished to a   Not paid under OPPS.
                       hospital outpatient       Paid by fiscal
                       that are paid under a     intermediaries under a
                       fee schedule or payment   fee schedule or payment
                       system other than OPPS,   system other than OPPS.
                       for example:
                       Ambulance
                       Services.
                       Clinical
                       Diagnostic Laboratory
                       Services.
                       Non-Implantable
                       Prosthetic and Orthotic
                       Devices.
                       EPO for ESRD
                       Patients.
                       Physical,
                       Occupational, and
                       Speech Therapy.
                       Routine
                       Dialysis Services for
                       ESRD Patients Provided
                       in a Certified Dialysis
                       Unit of a Hospital.
                       Diagnostic
                       Mammography.
                       Screening
                       Mammography.
B...................  Codes that are not        Not paid under OPPS.
                       recognized by OPPS when   May be paid by
                       submitted on an           intermediaries when
                       outpatient hospital       submitted on a
                       Part B bill type (12x     different bill type,
                       and 13x).                 for example, 75x
                                                 (CORF), but not paid
                                                 under OPPS.
                                                 An alternate
                                                 code that is recognized
                                                 by OPPS when submitted
                                                 on an outpatient
                                                 hospital Part B bill
                                                 type (12x and 13x) may
                                                 be available.
C...................  Inpatient Procedures....  Not paid under OPPS.
                                                 Admit patient. Bill as
                                                 inpatient.
D...................  Discontinued Codes......  Not paid under OPPS or
                                                 any other Medicare
                                                 payment system.
E...................  Items, Codes, and         Not paid under OPPS or
                       Services:                 any other Medicare
                       That are not      payment system.
                       covered by Medicare
                       based on statutory
                       exclusion..
                       That are not
                       covered by Medicare for
                       reasons other than
                       statutory exclusion..
                       That are not
                       recognized by Medicare
                       but for which an
                       alternate code for the
                       same item or service
                       may be available..
                       For which
                       separate payment is not
                       provided by Medicare..
F...................  Corneal Tissue            Not paid under OPPS.
                       Acquisition; Certain      Paid at reasonable
                       CRNA Services and         cost.
                       Hepatitis B Vaccines.
G...................  Pass-Through Drugs and    Paid under OPPS;
                       Biologicals.              Separate APC payment
                                                 includes pass through
                                                 amount.
H...................  (1) Pass-Through Device   (1) Separate cost-based
                       Categories.               pass-through payment;
                                                 Not subject to
                                                 coinsurance.
                      (2) Radiopharmaceutical   (2) Separate cost-based
                       Agents.                   non-pass-through
                                                 payment.
K...................  (1) Non-Pass-Through      (1) Paid under OPPS;
                       Drugs, Biologicals, and   Separate APC payment.
                      (2) Brachytherapy         (2) Paid under OPPS;
                       Sources.                  Separate APC payment.
                      (3) Blood and Blood       (3) Paid under OPPS;
                       Products.                 Separate APC payment.
L...................  Influenza Vaccine;        Not paid under OPPS.
                       Pneumococcal Pneumonia    Paid at reasonable
                       Vaccine.                  cost; Not subject to
                                                 deductible or
                                                 coinsurance.
M...................  Items and Services Not    Not paid under OPPS.
                       Billable to the Fiscal
                       Intermediary.
N...................  Items and Services        Paid under OPPS; Payment
                       Packaged into APC Rates.  is packaged into
                                                 payment for other
                                                 services, including
                                                 outliers. Therefore,
                                                 there is no separate
                                                 APC payment.
P...................  Partial Hospitalization.  Paid under OPPS; Per
                                                 diem APC payment.

[[Page 68385]]

 
Q...................  Packaged Services         Paid under OPPS;
                       Subject to Separate       Addendum B displays APC
                       Payment Under OPPS        assignments when
                       Payment Criteria.         services are separately
                                                 payable.
                                                (1) Separate APC payment
                                                 based on OPPS payment
                                                 criteria.
                                                (2) If criteria are not
                                                 met, payment is
                                                 packaged into payment
                                                 for other services,
                                                 including outliers.
                                                 Therefore, there is no
                                                 separate APC payment.
S...................  Significant Procedure,    Paid under OPPS;
                       Not Discounted when       Separate APC payment.
                       Multiple.
T...................  Significant Procedure,    Paid under OPPS;
                       Multiple Reduction        Separate APC payment.
                       Applies.
V...................  Clinic or Emergency       Paid under OPPS;
                       Department Visit.         Separate APC payment.
Y...................  Non-Implantable Durable   Not paid under OPPS. All
                       Medical Equipment.        institutional providers
                                                 other than home health
                                                 agencies bill to DMERC.
X...................  Ancillary Services......  Paid under OPPS;
                                                 Separate APC payment.
------------------------------------------------------------------------


                    Addendum D2.--Comment Indicators
------------------------------------------------------------------------
   Comment  indicator                       Descriptor
------------------------------------------------------------------------
NF.....................  New code, final APC assignment; comments were
                          accepted on a proposed APC assignment in the
                          proposed rule; APC assignment is no longer
                          open to comment.
NI.....................  New code, interim APC assignment; comments will
                          be accepted on the interim APC assignment for
                          the new code.
CH.....................  Active HCPCS code in current year and next
                          calendar year, status indicator and/or APC
                          assignment has changed; or active HCPCS code
                          that is discontinued at the end of the current
                          calendar year.
------------------------------------------------------------------------


    Addendum E.--CPT Codes That Are Paid Only as Inpatient Procedures
------------------------------------------------------------------------
        CPT/ HCPCS                 Description             CY 2007 SI
------------------------------------------------------------------------
00176....................  Anesth, pharyngeal surgery  C
00192....................  Anesth, facial bone         C
                            surgery.
00214....................  Anesth, skull drainage....  C
00215....................  Anesth, skull repair/fract  C
00452....................  Anesth, surgery of          C
                            shoulder.
00474....................  Anesth, surgery of rib(s).  C
00524....................  Anesth, chest drainage....  C
00540....................  Anesth, chest surgery.....  C
00542....................  Anesth, release of lung...  C
00546....................  Anesth, lung,chest wall     C
                            surg.
00560....................  Anesth, heart surg w/o      C
                            pump.
00561....................  Anesth, heart surg